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HEALTH  WORK  IN  THE 
SCHOOLS  - 


BY 


ERNEST  BRYANT  HOAG,  M.D. 

Director  of  School  Hygiene  ft/r  the  State 
Board  of  Health  for  Minnesota 


AND 


LEWIS  M.  IERMAN 

Associate  Professor  of  Education,  Leland  Stanford  Jr.  University 


HOUGHTON  MIFFLIN  COMPANY 

BOSTON    NEW  YORK    CHICAGO 

<$l)z  ftitoer?i&e  $re#$  Cambribae 


'""lipi"'"^^"'^^''^!!!!"!!!!! |l|ll''U||linMI|l|M»ll||||MMI|j||lii||||||M.|||||||.i|||||||.i|||,| l||||l>'ll|||ll"lt|||IIM|||||| |||l |j|H'>l|||| |j=- 

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\* 


COPYRIGHT,    1914,   BY  ERNEST  B.   HOAG  AND   LEWIS  M.  TERMAN 
ALL   RIGHTS   RESERVED 

%UJC  f)  J   OIL 


Wit  »toersfce  JJrcss 

CAMBRIDGE  .  MASSACHUSETTS 
V  .   S   .  A 


TO 
HENRY  M.  BRACKEN,  M.D. 

SECRETARY  OF  THE   STATE  BOARD   OF  HEALTH 
FOR  MINNESOTA 


EDITOR'S  INTRODUCTION 

Educational  Hygiene  has  four  chief  divisions:  (1) 
The  Hygiene  of  Physical  and  Mental  Growth;  (2) 
Health  Supervision  in  the  Schools,  including  methods 
of  health  observation  and  teaching;  (3)  the  Hygiene  of 
Instruction;  and  (4)  the  Hygiene  of  the  School  Plant. 

The  first  of  these  divisions  has  been  treated  by  one  of 
the  authors  of  this  book  in  The  Hygiene  of  the  School 
Child,  which  has  appeared  as  an  earlier  number  of 
this  Series,  and  the  third,  by  the  same  author,  is  in 
preparation.  The  fourth  division  is  to  be  covered  by 
another  author,  and  is  also  in  preparation. 

The  present  volume  deals  with  the  problems  in- 
volved in  health  supervision,  health  examination,  and 
hygiene  teaching,  —  in  other  words,  with  the  second 
of  the  above  divisions;  and  it  is  hoped  that  it  will  con- 
tribute materially  to  the  standardization  of  health 
supervision  and  to  the  broadening  of  its  scope.  Every 
one  must  realize  that  a  great  amount  of  what  goes  by 
the  name  of  "medical  inspection  of  schools"  can  be 
called  health  work  only  by  courtesy.  All  along  the 
line,  among  superintendents,  teachers,  school  nurses, 
school  boards,  and  even  school  doctors,  education  is 
needed  which  will  lend  a  broader  vision  to  the  purpose 
and  possibilities  of  genuine  health  supervision. 

Special  emphasis  has  been  given  by  the  authors  to 


viii  EDITOR'S  INTRODUCTION 

the  part  played  by  the  teacher  in  school  health  work. 
To  this  end,  two  chapters  have  been  prepared  (v  and 
vi)  for  the  purpose  of  assisting  teachers  in  the  observa- 
tion of  general  health  conditions  among  children,  and 
three  others  (ix,  x,  and  xi)  for  the  purpose  of  acquaint- 
ing them  with  the  most  important  facts  regarding  those 
transmissible  diseases  which  concern  the  school.  Three 
additional  chapters  (xv,  xvi,  and  xvn)  are  devoted  to 
suggestions  for  the  teaching  of  hygiene  in  the  grades, 
and  another  chapter  (xvm)  discusses  health  conditions 
among  teachers.  It  will  be  seen,  therefore,  that  the 
book  has  been  planned  primarily  for  the  use  of  the 
grade  teacher,  and  with  her  needs  especially  in  view, 
though  it  is  hoped  that  it  may  also  serve  as  a  handbook 
for  the  guidance  of  superintendents,  school  nurses,  and 
boards  of  education. 

It  is  seldom  that  we  have  presented,  by  authors  of 
such  extended  practical  experience  and  large  technical 
knowledge,  a  book  on  such  a  technical  subject  written 
in  such  simple  language  and  presented  in  so  attractive 
a  manner. 

Stanford  University,  Cal., 
May  6,  1914. 


CONTENTS 


CHAPTER  I 

Social  Responsibility  for  the  Health  of  School 

Children 1 

The  spread  of  school  medical  work.  Physical  defects 
among  school  children.  Parental  guardianship  of  children's 
health  not  sufficient.  The  responsibility  of  society.  The  rela- 
tion of  the  school  medical  service  to  private  medical  practice. 
Other  functions  of  school  health  departments.  The  reaction 
of  school  health  work  upon  the  home.  Opposition  to  school 
medical  work.  References. 

CHAPTER  II 

The  Scope  and  Administration  of  Health  Super- 
vision  15 

Stages  in  the  development  of  school  health  work.  The 
divisions  of  educational  hygiene.  Outline  of  the  scope, 
procedure,  and  administration  of  medical  supervision. 
Method  of  control.  Division  of  power.  Records.  Schools 
and  publicity.  References. 

CHAPTER  HI 

Plans  for  Organization  for  Health  Work     .    .    37 

State  versus  local  control.  Examples  of  state  departments. 
City  organization  of  school  health  supervision.  Plan  (1): 
Physician  and  nurses.  The  cost  of  health  supervision  by 
Plan  (1). 

CHAPTER  IV 

The   School  Nurse:   including   Suggestions   for 
Health  Supervision  by  the  "  Nurse  Alone  "  Plan    48 

Spread  of  school  nursing.  Nurses  necessary  for  follow-up 
work.  School  nurses  reduce  absence.  Other  functions  of  the 


CONTENTS 

school  nurse.  Influence  of  school  nurses  upon  the  home. 
Number  needed.  Equipment  needed  by  school  nurses.  A 
plan  for  the  health  supervision  of  schools  by  nurses  alone. 
Selected  references. 


CHAPTER  V 

The   Health    Grading  of    School  \  Children    by 
Teachers  

The  general  importance  of  the  teacher's  cooperation. 
Teachers  versus  physicians.  An  outline  for  the  health 
grading  of  school  children  by  teachers.  Health  survey.  Sug- 
gestions for  using  the  outline  for  health  grading.  The  signifi- 
cance of  the  answers  to  the  questions.  Some  results  secured 
by  the  outline  for  the  health  grading  of  school  children. 
References. 


CHAPTER  VI 

A  Demonstration  Clinic  for  Instruction  in  the 

Observation  of  Defects 90 

Verbatim  report  of  a  demonstration  clinic.  A  summary  of 
clinics  held  at  sixteen  cities. 


CHAPTER  Vn 

The  School  Medical  Clinic 109 

Difficulty  of  getting  results  from  medical  inspection. 
What  the  school  clinic  is.  Typical  school  medical  clinics  of 
England.  Cost,  equipment  and  management.  Why  free 
clinics  are  necessary.  The  opposition  to  free  school  clinics. 
To  protect  the  health  of  children  is  a  social  obligation. 
Summary.  References. 

CHAPTER  VIII 

School  Dentistry 125 

Historical.  Dental  clinics  should  be  free.  Preventing 
dental  decay.  References. 


CONTENTS 


CHAPTER  IX 

Transmissible  Diseases 133 

The  school  as  a  factor  in  the  spread  of  contagious  diseases. 
The  school  as  a  means  of  controlling  contagious  diseases. 
Newer  ideas  about  modes  of  infection.  Danger  of  the  com- 
mon cup,  common  towel,  etc.  Air  not  a  common  source  of 
infection.  Isolation  of  "carriers"  versus  school  closing. 
Ages  at  which  transmissible  diseases  most  often  occur. 


CHAPTER  X 

Transmissible  Diseases  (Continued) 148 

Measles.    Scarlet  fever.    Diphtheria.    Whooping-cough. 
Mumps.   Chickenpox.  Smallpox. 


* 


CHAPTER  XI 


Transmissible  Diseases  (Concluded) 175 

Tuberculosis.  Hookworm  disease.  Poliomyelitis  (Infan- 
tile paralysis).  Epidemic  Meningitis.  Contagious  eye 
diseases.  Contagious  diseases  of  the  skin.  General  sum- 
mary.  Selected  references. 

CHAPTER  XII 

Open-Air  Schools 198 

Recent  spread.  Program.  Results.  Pedagogical  results. 
References. 


CHAPTER  XIII 

School  Housekeeping        209 

School  dust  and  its  dangers.  Prevention  of  dust  by  means 
of  floor  oils.  Method  of  cleaning.  Other  ways  of  preventing 
dust.  Standards  of  cleanliness.  Professional  training  for 
janitors.  References. 


1 


CONTENTS 


CHAPTER  XIV 

The  Teaching  of  Hygiene:  The  First  Six  Grades  221 

Inculcating  health  habits.  Health  instruction  in  the  first 
five  grades.  Personal  hygiene  inspection  by  teacher  and 
pupils.  Inculcating  food  habits.  Vital  topics  of  hygiene 
study  for  grades  three  to  five.  Teaching  hygiene  in  the 
sixth  grade.  Hygiene  lessons  dramatized.  Outline  of 
scheme  for  teaching  hygiene  in  the  sixth  grade. 


CHAPTER  XV 

The  Teaching  of  Hygiene:  Seventh  and  Eighth 
Grades 236 

Early  instruction  must  deal  with  the  concrete.  Focus 
attention  upon  health  rather  than  upon  disease.  Practical 
instruction  in  bacteriology  for  the  seventh  and  eighth  grades. 
Teaching  hygiene  by  means  of  "sanitary  surveys."  Helps 
for  the  teaching  of  hygiene  in  the  grades. 

CHAPTER  XVI 

The  Teaching  of  Hygiene:  Education  with  Ref- 
erence to  Sex 252 

The  problem.  Need  of  safeguarding  school  children.  The 
school's  relation  to  sex-education.  Special  considerations 
relating  to  sex  education.  Methods  and  content  of  instruc- 
tion by  stages.  Divided  responsibility  of  the  home  and 
school  in  sex-education.  Selected  references. 


CHAPTER  XVII 

r 

The  Teacher's  Health 270 

Mortality  rate  and  physical  morbidity.  Premature  super- 
annuation. Tuberculosis  among  teachers.  The  teacher  as 
neurasthenic.  Health  suggestions  for  the  teacher.  The 
hygiene  of  character.  How  to  prevent  mental  fixation. 
The  responsibility  of  the  normal  school.  Vocational  guid- 
ance for  teachers.  References. 


CONTENTS  xiii 


CHAPTER  XVm 

What  the  World  is  doing  for  the  Health  of 
School  Children 285 

England.  Germany.  France.  Switzerland.  Sweden.  Den- 
mark. Norway.  Scotland.  Ireland.  Canada.  Australia. 
Japan.  Other  countries.  The  United  States.  Conclusion. 
References. 

APPENDIX 

School  Health  Organization  in  Various  Cities  of 
,the  United  States 305 

Milwaukee.  Minneapolis.  Philadelphia.  Oakland.  New 
York. 

Suggestions  for  a  Teacher's  Private  Library  in 
School  Hygiene 315 

GLOSSARY 317 

INDEX 319 

Note:  The  authorship  of  the  chapters  of  this  book  is  as  follows: 
Dr.  Hoag  — Chapters  III,  V,  VI.  IX,  X,  XI,  XIV,  and  XV. 
Prof.  Terman  —  Chapters  I,  II,  IV,  VII,  VIII,  XII,  XIII,  XVI, 
XVII,  and  XVIII. 


LIST  OF  ILLUSTRATIONS 


Facing 
School  nurse  recording  pulse  and  temperature  in  an  open-air 

class, 54 

Testing  vision 96 

Adenoids 98 

Crossed  eye  and  obstructed  breathing 99 

Testing  hearing   .  \    ._ 100 

Teeth  examination 101 

Chronological  and  physiological  age 106 

A  school  dental  clinic  in  Rochester,  New  York    ....  130 

Crooked  teeth 131 

Open-air  schools 200 

An  open-air  class  in  mid-winter,  Chicago 206 

Chicago  open-air  classes          207 

The  Muroscroll 216 


LIST  OF  FIGURES 


1.  Percentage  of  recommendations  acted  on  in  Philadelphia      .    50 

2.  Teeth  diagram 79 

3.  Weekly  average  qf  deaths  from  measles  in  London,  England  134 

4.  Curve  showing  number  of  cases  of  diphtheria*  in  Halle,  Ger- 

many      135 

5.  Curve  indicating  average  seasonal   occurrence  of  all  chil- 

dren's diseases  in  the  Berkeley  schools 145 

6.  Showing  the  average  weekly  gain  or  loss  in  weight  of  children 

attending  the  Bradford  Open- Air  School       ....  200 

7.  Haemoglobin  tests,  Providence  Open- Air  School      .       .       .  202 

8.  Curves  showing  changes  in  haemoglobin  during  school  year  .  203 


\JN1V.   OF 


HEALTH  WORK  IN  THE 
SCHOOLS 

CHAPTER  I 

SOCIAL  RESPONSIBILITY  FOR  THE  HEALTH  OF 
SCHOOL  CHILDREN 

The  spread  of  school  medical  work 

The  health  supervision  of  schools  is  not  a  passing 
fad.  The  conservation  of  the  child  is  a  problem  whichTi 
like  that  of  world  peace,  is  bound  to  take  possession  of^ 
the  minds  of  all  humanitarian  people.  MotEe'ethical 
principle  of  humanitarianism  is  added  the  stern  counsel 
of  biological  laws,  which  teach  us  that  an  elaborate  | 
scheme   of   mental   culture   which  proceeds  without  \ 
regard  to  the  needs  of  the  body  is  but  a  house  built   J 
upon  the  sands.  ***** 

It  is  significant  for  the  future  of  the  movement  that 
with  minor  exceptions  all  civilized  countries  have 
almost  simultaneously  taken  it  up.  Its  universal  de- 
velopment is  inevitable.  Progress  has  been  remarkably 
uniform  in  different  countries,  though  naturally  there 
are  some  differences  in  the  details  of  procedure  and  in 
the  points  of  emphasis.  Germany  lias  forged  ahead 
with  her  dental  clinics  and  open-air  schools;  France, 
with  her  school  lunches  and  vacation  colonies;  while 
England  has  set  the  whole  world  an  example  in  the 

\ 


2  HEALT K  ;  WORK  IN  THE  SCHOOLS 

earnest  way  inVhich  she  lias  undertaken  to  ameliorate 
the  evils  which  medical  inspection  of  schools  has 
revealed.  *Our  own  country,  on  the  whole,  is  behind 
most  of  the  nations  of  Europe  in  the  practice  of  school 
hygiene,  but  is  making  progress  rapidly.  But  the 
doctor  has  not  been  brought  into  the  school  without 
opposition,  and  it  is  therefore  desirable  to  inquire 
further  into  the  justification  for  this  new  assumption 
of  responsibility  on  the  part  of  organized  society. 

Physical  defects  among  school  children 

Serious  defects  of  eyes,  ears,  nose,  throat,  lungs, 
teeth,  glands,  nutrition,  heart  action,  nervous  co- 
ordination, and  mentality  have  been  discovered  with 
surprising  frequency  wherever  they  have  been  looked 
for.  Statistics  on  these  matters  have  been  so  indefi- 
nitely extended  and  (when  we  make  allowance  for  cer- 
tain differences  in  procedure)  have  given  such  uniform 
results,  that  we  can  safely  say  that  in  any  school  sys- 
tem, no  matter  where  it  may  be  located  or  to  what 
social  classes  its  patrons  belong,  from  50  to  75  per  cent 
of  its  pupils  are  suffering  from  one  or  more  physical 
defects  serious  enough  to  require  skilled  attention.1 

While  it  is  not  claimed  that  all  this  defectiveness  is 
produced  by  the  school,  some  of  it  undoubtedly  is,  and 
in  the  case  of  still  other  pupils  the  school  is  at  least  a 
partial  cause.  At  any  rate,  it  is  well  known  that  defec- 
tive pupils  are  present  in  the  schools  in  large  numbers, 

1  Lewis  M.  Terman,  The  Hygiene  of  the  School  Child,  chapter  I. 
Houghton  Mifflin  Co.,  1914. 


SOCIAL  RESPONSIBILITY  3 

and  that  the  defects  are  often  unfavorable  to  a  normal 
physical  and  mental  development.  Although  many  of 
the  defects  are  curable  or  preventable,  as  a  rule  even 
intelligent  parents  and  teachers  either  do  not  observe 
them  or  else  they  underestimate  their  seriousness. 


Parental  guardianship  of  children's  health  not 
sufficient 

If  all  parents  were  wise  in  regard  to  health  matters, 
it  would  not  be  so  necessary  for  schools  to  make  a 
pecial  study  of  the  physical  conditions  of  the  children 
entrusted  to  their  care.  All  that  could  then  be  fairly\ 
required  would  be  the  guaranty  of  a  healthful  school 
environment,  including  such  things  as  good  ventila- 
tion, correct  methods  of  lighting  and  heating,  sanitary 
plumbing,  the  control  of  contagious  diseases,  frequent 
recesses,  sufficient  physical  training,  and  the  proper 
sort  of  health  instruction.  But  it  is  a  fact  and  not  a 
theory  that  not  all  parents  possess  the  special  knowl- 
edge which  is  necessary  for  the  hygienic  supervision  of 
physical  and  mental  development.  Even  intelligent 
parents  may  be  unable  to  detect  the  early  symptoms  of 
physical  disorder,  just  as  they  may  be  unable  to  decide 
upon  the  best  methods  or  texts  for  teaching  history  or 
geography.  They  do  not  see  the  defects  in  their  own 
children  because  they  are  used  to  them.  Many  are  so 
superstitious  as  to  prefer  to  treat  adenoids  by  sugges- 
tion, others  so  ignorant  as  to  interpret  pediculosis 
capitis  as  a  sign  of  good  health.  Plainly,  therefore,  it 
becomes  the  duty  of  the  school  department  to  furnish 


I 


4  HEALTH  WORK  IN  THE  SCHOOLS 

not  only  a  healthful  school  environment,  but  also  a 
health  guardianship  over  its  pupils. 

The  responsibility  of  society 

^~The  children  of  to-day  must  be  viewed  as  the  raw 
material  of  a  new  State;  the  schools  as  the  nursery  of 
the  Nation.  To  conserve  this  raw  material  is  as  logical 
a~lunction  of  the  State  as  to  conserve  the  natural 
resources  of  coal,  iron,  and  water  power.  To  investi- 
gate exhaustively  the  evils  which  exist  and  to  remedy 
all  that  may  be  remedied  without  transgressing  unduly 
upon  the  jealous  precincts  of  parental  responsibility  is 
a  plain  matter  of  duty.  Theoretically,  it  matters  little 
how  the  State  performs  this  duty,  whether  by  a  house- 
to-house  census  of  the  children,  or  in  some  other  way. 
Practically,  however,  there  is  no  effective  or  conven- 
ient way  except  to  do  the  work  in  connection  with  the 
public  schools.  In  many  of  our  best  towns  and  cities 
the  people  themselves  are  demanding  such  supervision 
on  the  principle  that  it  is  one  of  the  important  func- 
tions of  the  public  school  system. 
I"The  argument  that  the  health  supervision  of  schools 
invades  the  rights  of  the  home  has  exactly  the  same 
value  as  the  corresponding  argument  against  com- 
pulsory school  attendance  and  prescribed  courses  of 
study.  The  school  does  not  claim  anything  more  than 
the  right  to  make  an  examination  of  the  child's  physi- 
cal and  mental  condition  in  order  that  the  work  of  the 
school  may  be  properly  adjusted  to  his  health  and 
growth  needs,   and,   further,   to  notify   and   advise 


SOCIAL  RESPONSIBILITY  5 

parents  regarding  such  defects  as  are  found  to  exist. 
This  is  not  an  unwarranted  assumption  of  power.  The 
responsibility  for  remedial  action  is  left  entirely  with 
parents.  The  school  has  not  undertaken  forcibly  to 
subject  children  to  surgical  operations,  nor  is  there  at 
present  any  legal  method  of  compelling  parents  to  per- 
form their  duty  in  this  respect.  We  can  invoke  the  law 
for  wanton  neglect  of  a  broken  bone,  but  there  is 
no  way  to  punish  the  neglect  of  discharging  ears, 
adenoids,  or  astigmatism,  any  one  of  which  may 
prove  more  serious  in  the  long  run  than  a  fractured 
bone. 

It  is  interesting  to  conjecture  how  far  present  prac- 
tice in  this  respect  is  likely  to  be  modified.  Compulsory 
public  education  itself  is  so  recent  that  only  a  few  dec- 
ades ago  it  was  considered  by  a  majority  of  people  as  a 
species  of  meddlesome  paternalism.  According  to  the 
old  conception  the  child  was  the  parents'  child;  if  they 
questioned  the  value  of  an  education  there  was  no 
recourse  in  the  child's  behalf.  There  are  a  million  or 
more  illiterate  adults  in  the  United  States  to-day 
who  are  victims  of  this  mistaken  social  theory.  The 
theory,  happily,  has  been  discarded.  We  now  know 
that  the  interests  of  society  demand  an  elaborate 
scheme  of  educational  processes  under  social  control. 
Some  time  we  shall  understand,  just  as  clearly,  that 
the  child's  physical  growth  also  stands  in  need  of  more 
expert  supervision  than  the  average  parent  is  capable 
of  exercising. 


V 


6  HEALTH  WORK  IN  THE  SCHOOLS 

The  relation  of  the  school  medical  service  to  private 
medical  practice 

It  is  sometimes  contended  that  all  medical  work 
should  be  left  in  the  hands  of  the  family  doctor,  and 
that  the  employment  of  school  physicians  is  both  an 
impertinence  and  a  needless  expense.  The  practicing 
physician  himself  often  takes  this  stand,  just  as  for- 
merly private  teachers  resented  the  intrusion  into  their 
domain  of  teachers  who  were  paid  at  public  expense. 
The  two  situations  are  strikingly  similar.  There  were 
private  schools  which  afforded  excellent  educational 
opportunities,  but  unfortunately  they  did  not  reach 
all  the  people  and  they  were  excessively  expensive. 
Similarly  there  are  families  who  know  enough  about 
health  and  the  causes  which  are  likely  to  undermine 
it  to  seek  the  frequent  advice  of  high-priced,  skill- 
ful physicians.  On  the  other  hand,  a  large  majority  of 
families  can  hardly  be  said  to  have  a  family  physician, 
and  when  they  do  his  function  seldom  goes  beyond  the 
treatment  of  acute  disease  or  physical  injury.  Under 
present  conditions  the  family  doctor  institution  hardly 
touches  the  rich  field  of  preventive  medicine  with 
which  it  is  the  business  of  the  school  physician  to  deal. 
In  the  vast  majority  of  cases,  if  the  child's  physical 
needs  receive  no  expert  oversight  in  the  school,  they 
will  receive  no  expert  attention  at  all. 

It  is,  therefore,  not  at  all  a  question  of  relieving  the 
family  physician  of  any  of  the  functions  he  has  been 
accustomed  to  exercise,  but  of  doing  the  work  he  has 


SOCIAL  RESPONSIBILITY  7 

left  undone.  The  practicing  physician  is  not  always 
present  when  needed.  As  a  rule  he  does  not  appear  on 
the  scene  until  an  emergency  occurs.  He  has  no  com- 
mission to  go  out  in  quest  of  disease.  He  has  little  op- 
portunity so  to  order  the  lives  of  his  clients  that  they 
will  escape  emergencies.  We  refuse  to  pay  him  except! 
to  cure  our  diseases;  it  is  unfair  as  well  as  absurd, 
therefore,  to  expect  that  his  chief  interest  will  be  in  the 
prevention  of  disease.  The  wonder  is  that  the  disparity 
between  the  physician's  interest  in  disease  and  his  in- 
terest in  health  is  not  greater.  It  is  to  the  credit  of  the 
profession  that  the  better  class  of  practicing  physicians 
almost  unanimously  indorse  the  work  the  schools  have 
undertaken  in  child  hygiene. 

Other  functions  of  school  health  departments 

Apart  from  its  contribution  to  national  vitality,  the 
health  supervision  of  schools  is  entirely  justified  by  its 
influence  upon  the  efficiency  of  the  school  itself.  For  s 
one  thing,  it  appreciably  affects  regularity  of  attend-/ 
ance,  which,  as  Ayres  has  shown,  is  one  of  the  im- 
portant factors  in  retardation.  It  does  this  by  elimi- 
nating some  of  the  causes  of  illness,  and  by  treating  in 
the  school  certain  parasitic  diseases  and  other  slight 
ailments  which  otherwise  would  require  exclusion. 
Ringworm  and  pediculosis,  especially,  have  in  the  past 
caused  a  great  deal  of  needless  irregularity  of  attend- 
ance. Chronic  physical  defects,  particularly  of  breath- 
ing and  of  nutrition,  have  a  retarding  effect  on  school 
progress,  even  when  they  are  not  of  such  a  nature  as  to 


8  HEALTH  WORK  IN  THE  SCHOOLS 

cause  absence.  To  the  extent  that  health  supervision 
of  schools  is  successful  in  securing  the  medical  or  sur- 
gical treatment  of  defects,  or  in  ameliorating  environ- 
mental conditions  in  the  home,  it  cannot  fail  to  con- 
tribute to  the  solution  of  the  retardation  question. 

In  the  prevention  of  epidemics  the  school  depart- 
ment of  health  renders  invaluable  assistance  to  the 
local  non-educational  board  of  health.  The  latter  is 
usually  given  authoritative  control  in  such  matters  as 
closing  the  schools,  granting  permits  to  return  after 
illness,  etc.,  but  the  closer  contact  of  the  school  health 
officer  with  the  pupils  often  enables  him  to  sound  the 
alarm  and  in  many  ways  to  become  a  necessary  ally  in 
preventing  the  spread  of  infectious  diseases. 

Not  the  least  important  function  of  the  school 
health  department  is  that  of  cooperation  with  the 
school  architect  and  sanitary  engineers.  /  Of  the  mil- 
lions of  dollars  expended  annually  in  the  United 
States  for  school  buildings,  a  large  part,  from  the  point 
of  view  of  school  hygiene,  must  be  considered  as 
almost  wasted.  School  buildings  erected  earlier  than 
twenty  years  ago  belong  usually  to  discredited  types 
of  architecture,  and  are  being  replaced  rapidly  by  new 
and  still  more  expensive  plants.  Unless  these  embody 
the  very  best  ideas  in  sanitation  and  hygiene,  they, 
too,  will  soon  have  to  be  replaced.  There  is  no  reason 
why  the  better  class  of  school  buildings  erected  to-day 
should  not  be  well  preserved  and  for  the  most  part 
hygienic  in  the  year  2000.  It  would  be  hard  to  over- 
estimate the  injury  that  may  be  wrought  in  three 


SOCIAL  RESPONSIBILITY  9 

quarters  of  a  century  by  a  poorly  lighted,  ill-ventilated, 
or  unsanitary  school  building  of  twenty-five  rooms. 
Within  that  time  many  thousands  of  children  will  have 
been  subjected  to  its  unwholesome  influence.  The  re- 
sulting sickness,  ill  health,  and  death  would  appall  us, 
if  it  were  possible  to  estimate  it. 

The  health  department  will  also  give  immediate 
returns  in  the  hygienic  supervision  of  school  activities. 
Competitive  athletics,  for  example,  are  always  danger- 
ous without  such  control,  particularly  below  the  col- 
lege age.  Likewise  the  hygiene  of  instruction  presents 
a  promising  field  of  research  that  can  best  be  carried  on 
by  official  investigation  supported  by  the  school  itself. 
There  is  hardly  a  limit  to  the  number  of  hygiene  re- 
searches which  it  would  be  feasible  for  the  school  to 
undertake. 

Furthermore,  the  department  of  health  would  give 
valuable  assistance  to  the  teaching  corps  in  hygiene 
teaching.  At  present  hygiene  is  one  of  the  least  taught, 
and  probably  also  the  worst  taught,  of  all  the  branches 
of  the  curriculum.  This  is  largely  because  the  teachers 
themselves  have  been  poorly  instructed  in  the  subject. 
The  work  of  the  health  department  in  this  respect  is 
twofold:  (1)  It  will  give  the  teachers  themselves  sys- 
tematic instruction  in  the  hygiene  of  physical  and 
mental  development,  so  that  they  may  cooperate  in- 
telligently with  the  work  of  the  department;  and  (2)  it 
will  aid  the  teachers  in  the  choice  of  subject-matter  and 
in  the  methods  of  presenting  hygiene  lessons  in  the 
schools. 


10  HEALTH  WORK  IN  THE  SCHOOLS 

Finally,  health  supervision  in  the  schools  will  con- 
tribute to  the  conservation  of  the  teacher's  health. 
This  has  been  fully  presented  in  chapter  xvm,  and 
need  not  be  dwelt  upon  here. 

The  reaction  of  school  health  work  upon  the  home 

But,  supposing  that  all  defects  have  been  discovered, 
and  that  school  life  goes  on  without  aches  and  pains, 
must  we  go  all  over  the  work  next  year  and  the  next, 
forever?  Is  the  social  mill  to  go  on,  indefinitely,  grind- 
ing out  diseased  and  crippled  children  by  the  thou- 
sands? The  most  hopeful  approach  to  this  problem  lies 
in  the  schools  themselves.  By  all  means  let  us  remedy 
defects  when  they  exist,  but,  in  addition,  let  us  en- 
deavor to  prevent  defects  from  occurring.  The  school 
must  investigate  the  home  conditions  of  defective 
pupils.  It  must  know  more  of  the  child's  habits,  what 
time  he  goes  to  bed,  how  long  he  sleeps,  how  much  he 
works,  how  much  he  studies  at  home,  what  he  eats, 
what  he  drinks,  where  and  under  what  conditions  he 
sleeps,  and  what  the  home  environment  is  in  every 
particular  that  concerns  the  child's  health.  If  we  read 
the  lesson  of  the  health  index  aright,  it  means  not  only 
sick  school  children,  but  sick  school  buildings  and  sick 
homes  as  well.  The  health  of  the  child  reflects  the 
health  of  the  community  in  which  he  lives. 

The  surest  means  of  increasing  community  health 
are:  (1)  by  increasing  the  health  of  the  child  through 
improved  school  conditions,  and  by  attention  to  his 
physical  defects;  (2)  by  teaching  the  child  sensible,  ap- 


SOCIAL  RESPONSIBILITY  11 

plieable  health  lessons;  (3)  by  carrying  the  influences  of 
this  health  improvement  and  health  instruction  into 
the  home. 

The  public  school  has  not  fulfilled  its  duty  when  the 
child  alone  is  educated  within  its  walls.  The  school 
must  be  the  educational  center,  the  social  center,  and 
the  hygienic  center  of  the  community  in  which  it  is 
located,  —  a  hub  from  which  will  radiate  influences 
for  social  betterment  in  many  lines. 

Opposition  to  school  medical  work 

Thus  far  the  opposition  to  health  supervision  in  the 
schools  comes  from  three  chief  sources.  One  of  these  is 
the  misconception  as  to  the  purpose  of  the  work  which 
is  likely  to  be  entertained  by  the  more  ignorant  people 
of  a  school  community.  At  first  such  people  are  likely 
to  become  panic-stricken  with  the  foolish  notion  that 
their  children  may  be  subjected  to  some  strange  kind 
of  violence,  forcible  surgical  attention,  hypnotism,  etc. 
As  the  school  health  officer  becomes  a  more  familiar 
figure  about  the  school  premises,  and  as  his  kindly  in- 
terest in  the  children  becomes  known,  this  fear  always 
disappears. 

The  two  other  sources  of  opposition  are  harder  to 
eradicate,  because  founded  on  prejudice  rather  than 
ignorance.  These  are  the  Christian  Scientists,  and  the 
League  for  Medical  Freedom. 

The  tenets  of  the  former  are  so  well  known  that  they 
need  not  be  discussed  here.  It  is  well  to  note,  however, 
that  the  attitude  of  Christian  Scientists  toward  school 


V 


12  HEALTH  WORK  IN  THE  SCHOOLS 

health  work  is  not  always  unfriendly  where  the  purely 
advisory  capacity  of  the  school  doctor  is  understood. 
On  the  other  hand,  where  the  school  authorities,  in 
their  communications  and  notices  to  parents,  are  at 
all  insistent  in  their  efforts  to  bring  about  the  correc- 
tion of  defects,  the  enmity  of  this  religious  sect  is  likely 
to  be  aroused.  Notwithstanding  certain  hygienic 
principles  in  Christian  Science,  its  sweeping  warfare 
against  medicine  must  be  viewed  as  the  conflict  of  an 
absurd  superstition  with  the  welfare  of  the  State  and 
its  children.  Superstition  has  had  to  yield  to  quaran- 
tines and  to  state  laws  which  punish  parental  neglect 
in  case  of  acute  and  immediately  dangerous  diseases. 
Here,  also,  it  will  have  to  adjust  itself  as  best  it  can  to 
the  march  of  science,  which,  at  last,  is  beginning  to 
question  the  right  of  either  parental  or  religious  au- 
thority to  interfere  with  the  health  or  safety  of  the 
child. 

The  League  for  Medical  Freedom  is  a  less  worthy, 
but  a  more  active  and  dangerous,  opponent  of  child 
hygiene  measures.  This  is  a  recently  founded  and 
vigorous  organization  composed  largely  of  "sectarian" 
physicians,  quacks,  and  patent-medicine  vendors, 
whose  main  purpose  seems  to  be  to  oppose  all  social 
restraints  on  medical  practice  and  to  preserve  the 
divine  right  of  all  kinds  of  practitioners,  regular  and 
irregular,  to  prey  upon  the  gullibility  of  the  people.  In 
the  short  time  since  it  was  organized,  it  has  in  several 
cases  successfully  opposed  the  extension  of  school 
medical  inspection,  and  has  defeated  progressive  legis- 


SOCIAL  RESPONSIBILITY  13 

lation  on  matters  relating  to  hygiene  and  medical 
practice  generally. 

Its  methods  are  always  and  everywhere  the  same  — 
to  prejudice  the  minds  of  those  not  alive  to  the  real 
issue  by  the  cry  of  "medical  tyranny,"  "political  doc- 
tors," "  sacred  rights  of  the  family,"  etc.  Teachers  will 
not  be  deceived  by  catchwords  of  this  sort,  enlisted  in 
the  cause  of  the  patent-medicine  industry  and  quack 
schools  of  "healing."  Teachers  are  intelligent  enough 
to  scent  the  insincerity  in  the  argument  that  medical 
inspection  is  being  fostered  for  the  special  benefit  of  a 
particular  "school"  of  medicine,  —  the  allopathic 
versus  the  hydropathic,  homoeopathic,  osteopathic, 
naturopathic,  etc.  It  is  well  for  teachers  to  understand 
that  real  medical  science  is  not  torn  asunder  by  sepa- 
rate schools,  any  more  than  is  the  science  of  chemistry 
or  physics.  There  is  only  medical  science  on  the  one 
hand,  and  quackery  and  superstition  on  the  other. 

All  such  opposition  will  gradually  be  dissipated,  or 
at  least  silenced.  Medical  inspection,  enlarged  to  in- 
clude all  phases  of  school  hygiene,  will  soon  be  looked 
upon  as  a  mere  matter  of  course,  —  the  logical  and 
necessary  correlate  of  compulsory  education. 

REFERENCES 
(The  most  important  references  are  indicated  by  a  *) 

1.  Allen,  W.  H. :  "  A  Broader  Motive  for  School  Hygiene."  Atlan- 
tic Monthly,  June,  1908. 

2.  Blan,  Louis:  "  Are  we  taking  Proper  Care  of  the  Health  of  our 
Children?  "  Ped.  Sem.,  1912,  pp.  220-27. 

S.  Burnham,  W.  H.:  "Health  Inspection  in  the  Schools."    Ped. 
Sem.,  1900,  pp.  70-94. 


14  HEALTH  WORK  IN  THE  SCHOOLS 

*4.  Dresslar,  F.  B.:  "The  Duty  of  the  State  in  the  Medical  Inspec- 
tion of  Schools."   Bull.  ^96,  U.S.  Bur.  of  Ed.,  1912. 

5.  Fisher,  Irving:  "  Public  Responsibility  for  the  Health  of  Infants 
and  Children."   Fed.  Sem.,  1909,  pp.  395-402. 

6.  Gorst,  Sir  John  E.:  The  Children  of  the  Nation.    (Chapter  iv, 
pp.  50-66.) 

*7.  Gulick  and  Ayres:  Medical  Inspection  of  Schools.  1913,  pp.  224. 
(Chapter  i.) 

8.  Gulick,  Luther  H.:  "Constructive  Community  and  Personal 
Hygiene."   Science,  1910,  pp.  801-10. 

9.  Cronin,  John  J.:  "The  Doctor  in  the  Public  School."  Review  of 
Reviews,  1907,  pp.  433-40. 

10.  Forsyth,  David:  Children  in  Health  and  Disease.  1909,  pp.  360. 

(Chapter  vi.) 
*11.  Hall,  G.  Stanley:  "The  Medical  Profession  and  Children." 

Fed.  Sem.,  1908. 
*12.  Hogarth,  A.  H:  Medical  Inspection  of  Schools.   1909,  pp.  360. 

(Chapters  in  to  vni,  inclusive.) 
*13.  Moore,  Benjamin:  The  Dawn  of  the  Health  Age.    Liverpool, 

1910,  pp.  204. 
14.  Osier,   Dr.   William:   "Medical   and  Hygiene   Inspection  of 

Schools."   Rept.  Inter.  Cong.  Sch.  Hyg.,  1907,  pp.  465-68. 
*15.  Terman,  Lewis  M.:  The  Hygiene  of  the  School  Child.    1913. 

(Chapter  i.) 

See  Collier  s  Weekly,  June  3, 1911,  for  an  expose  of  the  "League 

for  Medical  Freedom." 

See  all  standard  works  on  school  hygiene  or  medical  inspection 

of  schools. 


CHAPTER  II 

THE  SCOPE  AND  ADMINISTRATION  OF 
HEALTH  SUPERVISION 

Stages  in  the  development  of  school  health  work 
The  health  supervision  of  schools  presents  three 
clearly  defined  stages  in  its  development:  — 

(1)  Its  original  purpose  in  almost  every  case  was  the 
detection  of  contagious  disease.  The  work  was  merely 
an  extension  of  that  of  the  local  board  of  health,  and 
was  designed  to  protect  the  community  from  epidem- 
ics. The  value  of  such  inspection  immediately  became 
evident. 

(2)  The  second  stage  is  represented  by  the  extension 
of  the  scope  of  the  work  to  include  examinations  for 
non-contagious  physical  defects.  The  early  surveys 
of  the  Danish  and  Swedish  commissions  had  dem- 
onstrated an  enormous  prevalence  of  defectiveness 
among  supposedly  normal  children  of  both  sexes  and 
of  all  ages  and  classes.  It  was  discovered  that  many  of 
these  defects  have  a  bearing  upon  the  child's  school 
progress,  and  upon  his  physical  development.  It  was 
observed,  moreover,  that  many  of  them  are  easily 
curable  or  removable.  About  two  hundred  cities  in  the 
United  States,  mostly  the  larger  ones,  have  under- 
taken to  give  their  school  children  complete  examina- 
tions for  all  kinds  of  physical  defectiveness. 


16  HEALTH  WORK  IN  THE  SCHOOLS 

(3)  The  third  stage  passes  beyond  "medical  inspec- 
tion," as  such,  and  becomes  a  distinct  field  of  preven- 
tive medicine.  A  suitable  name  for  it  is  "Health  and 
Development  Supervision."  fits  keynote  is  the  cultiva- 
tion  of  healthand  the  prevention  of  defectiveness  by 
the  hygienic  supervision  of  all  the  school  activities. 

This  phase  of  child  hygiene,  the  most  important  of 
all,  is  just  in  its  beginning.  Health  supervision  has 
been  too  narrowly  conceived,  but  we  are  coming  to 
realize  that  almost  everything  which  contributes  to 
the  conservation  of  the  child  belongs  within  its  scope. 
The  schools,  instead  of  causing  sickness  and  defective- 
ness, must  be  made  to  preserve  the  child  from  many 
kinds  of  morbidity,  repair  his  already  existing  defects, 
and  combat  his  hereditary  predisposition  to  illness 
and  the  unfavorable  conditions  of  his  social  environ- 
ment. 

In  order  to  prosecute  the  work  intelligently  hun- 
dreds of  researches  will  have  to  be  made;  researches  to 
which  the  public  schools  must  be  freely  thrown  open, 
and  for  the  support  of  which  public  funds  should  be 
appropriated.  Out  of  the  data  from  such  investiga- 
tions there  will  rise,  gradually,  a  new  science  of  educa- 
tional hygiene  which  will  go  as  far  beyond  the  usual 
poverty-stricken  courses  in  "school  hygiene"  as  medi- 
cal science  now  transcends  the  teachings  of  the  eight- 
eenth-century medical  school.1  pit 

The  broad  scope  of  educational  hygiene  is  made 
clear  in  the  following  outline,  which  is  a  modifica- 
1  See  Popular  Science  Monthly,  1912,  pp.  289-97. 


SCOPE  AND  ADMINISTRATION  17 

tion  of  the  comprehensive  suggestions  of  Louis  W. 
Rapeer.1 

The  Divisions  of  Educational  Hygiene 

I.  School  sanitation. 

A.  School  sites,  hygienic  aspects. 

B.  School  architecture,  hygienic  aspects. 

C.  Ventilation  and  humidification. 

D.  Lighting. 

E.  Heating. 

F.  Drinking-water  and  fountains. 

G.  School  baths. 
H.  School  cleaning. 

I.  School  toilets. 
J.  Seating. 
K.  Decoration. 
L.  The  standard  schoolroom. 
M.  Janitor  service. 

II.  Physical  education. 

A.  Playgrounds  and  play. 

B.  Athletics  and  "leagues." 

C.  Physical  training. 

D.  Correctional  exercises. 

E.  Posture. 

F.  Recreation. 

G.  School  excursions,  "tramps." 

H.  Physical  development  examinations. 

I.  Gymnasiums  and  gymnastics. 

J.  Swimming  and  bathing. 

K.  Medical  gymastics. 

L.  Social  center  work  for  adults. 

III.  Health  teaching. 

A.  Choice  of  hygiene  texts. 

B.  Health  instruction  topics. 

1  The  authors  are  indebted  to  Dr.  Louis  W.  Rapeer  for  permission 
to  include  this  valuable  outline  in  the  present  volume.  No  one  else 
has  made  such  a  thorough  study  of  efficiency  in  school-health  serv- 
ice as  Dr.  Rapeer. 


18  HEALTH  WORK  IN  THE  SCHOOLS 

C.  Health  habits. 

D.  Public  and  personal  hygiene. 

E.  Health  education  of  parents. 

F.  Feeding  and  clothing  of  children. 

G.  Health  education  of  teachers. 

H.  Home  hygiene,  in  domestic  science. 

I.  Industrial  hygiene,  in  industrial  work. 

J.  First  aid  and  avoidance  of  accidents. 

K.  Talks  by  doctors,  nurses,  and  specialists. 

L.  Pupil's  cooperation  in  medical  supervision. 

M.  Health  leaflets. 

IV.    The  hygiene  of  instruction  and  of  mental  development. 

A.  Fatigue. 

B.  School  program. 

C.  Home  study. 

D.  Examinations. 

E.  Type  of  books. 

F.  Motor  aspects  of  teaching. 

G.  Cheerfulness  and  calmness. 
H.  Part  time  or  whole  time. 

I.  Vacations  and  their  influence. 

J.  Teaching  through  play. 

K.  Attention  and  inter-recitation  recreation. 

L.  Preventing  pathological  conditions. 

M.  The  hygiene  of  discipline. 

N.  The  hygiene  of  classification,  promotion,  and 
gradation. 

O.  The  hygiene  of  mentally  exceptional  children ;  the 
nervous,  the  feeble-minded,  etc. 

P.  The  hygiene  of  the  learning  process,  habit  forma- 
tion, etc. 

V.  Medical  supervision. 

Each  of  the  above  divisions  should  have  its  special 
texts,  and  its  special  courses  in  teacher's  colleges  and 
normal  schools.  Space  is  lacking  to  show  in  detail  the 
contents,  aim,  and  procedure  for  each  division,  but 


SCOPE  AND  ADMINISTRATION  19 

this  will  be  done  for  Division  V,  Medical  Supervision. 
The  following  outline,  based  upon  Rapeer's  conclusions 
from  his  valuable  comparative  study  of  medical  su- 
pervision in  twenty -five  American  cities,  reveals  the 
scope  and  procedure  for  one  of  the  five  divisions  given 
above:  — 

Outline  of  the  Scope,  Procedure  and  Administration 
of  Medical  Supervision 

A.  Officials. 

1.  General  director  of  the  department  of  hygiene. 

2.  Medical  examiners. 

3.  Nurses. 

4.  Oculists,  dentists  and  surgeons  at  school  clinics  and 

dispensaries. 

5.  Teachers,  principals,  and  superintendents. 

6.  Physical-training  teachers. 

7.  Board  of  health. 

8.  Sanitary  inspectors. 

9.  Health  lecturers. 

B.  Phases  of  work  of  medical  supervision. 

1.  Preliminary  working  together  of  all  doctors  and 
nurses,  with  teachers  present  as  much  as  possible 
for  standardization. 

%.  Inspections. 

a.  September  room  inspection  of  all  pupils. 

b.  Occasional  room  inspection  by  nurses. 

c.  Individual  inspection  by  teachers  and  nurses, 
teachers  to  refer  suspicious  cases  with  help  of 
symptom  chart.  Nurse  to  inspect,  also,  all 
pupils  absent  for  three  or  more  days,  and 
entering  pupils.  Doctor  to  make  individual 
inspection  of  urgent  cases. 

d.  Home-hygiene  inspection  by  nurses.  Re- 
corded on  pupil's  health-record  card. 

e.  Sanitary  inspection  of  school.  By  superin- 
tendent of  school  or  representative:  doctor, 


20  HEALTH  WORK  IN  THE  SCHOOLS 

nurse,  principal,  business  manager,  or  sanitary 
inspector. 

3.  Examinations  —  Complete  physical,  annually,  for 
pupils. 

a.  Medical  —  only  such  phases  by  the  doctor  as 
the  nurse  cannot  do  well. 

b.  Vision,  hearing,  teeth,  scalp,  skin,  —  by  the 
nurse. 

c.  Height,  weight,  chest-expansion,  and  other 
measurements,  if  required  —  by  nurse,  physi- 
cal trainers,  or  principals. 

4.  Cure  and  correction. 

a.  Treatments  by  the  home  through  school 
advice  and  family  physicians. 

b.  Treatments  by  school  nurses  and  clinics. 

c.  Follow-up  work  in  getting  or  keeping  up  treat- 
ment. 

d.  Prescriptions  for  simple,  common  ailments,  so 
far  as  safe,  in  the  language  of  the  people. 

e.  Getting  cooperation  of  dispensaries,  boards  of 
health,  etc. 

/.  Testing  efficiency  by  cures  and  improvements. 
g.  Health-budget  exhibits,  and  other  means  of 
health  education. 
i  5.  Central  office  where  parents  may  bring  children  for 
special  examinations  and  for  consultation,  includ- 
ing psychological  tests. 
6.  Prevention. 

a.  Good  ventilation,  fresh-air  or  open-air  rooms 

or  schools. 
6.  Summer  inspection  by  nurses,  at  playgrounds 
and  summer  schools. 

c.  Special  inspections,  to  prevent  epidemics. 

d.  Improved  instruction  of  pupils  and  parents  in 
hygiene. 

e.  Cooperation  with  health  and  recreation  agen- 
cies. 

/.  Daily  inspection,  by  nurses. 
g.  Testing  efficiency  by  decrease  of  ailments  and 
defects. 


SCOPE  AND  ADMINISTRATION  21 

h.  Efficient  supervision  of  doctors  and  nurses. 
ft.  Limiting  medical  inspectors  largely  to  examin- 
ations. 
j.  Coordinating  all  phases  of  educational  hygiene. 
k.  Continued  home-hygiene  inspection. 

Records  and  reports. 

1.  Individual,  cumulative  health-record  card. 

a.  The  central  instrument  of  medical  supervi- 
sion, as  nurse  is  the  central  agent. 

b.  Should  provide  for  entire  health  record,  includ- 
ing inspections,  examinations,  and  records  of 
cures  and  improvements. 

c.  Should  have  the  good  features  of  the  Cleve- 
land, Ohio,  the  Meriden,  Connecticut,  and  Dr. 
W.  S.  Cornell's  cards  (and,  perhaps,  those  of 
the  New  York  City  card  for  both  health  and 
scholastic  record). 

d.  May  be  kept  in  the  classrooms  for  teachers' 
constant  reference  and  carried  by  pupils  to 
inspection  or  examination. 

e.  Doctor's  findings  on  the  twenty  or  more  exam- 
ination cards  daily  should  be  left  for  the  nurse 
to  report,  before  cards  are  returned,  to  the 
rooms.  Doctor  may  be  relieved  of  most  clerical 
work,  if  results  are  supervised,  thus  saving 
time. 

/.  To  distinguish,  nurse  should  make  records  on 

cards  in  red  ink,  doctor  in  black, 
g.  State  or  national  cards  should  be  adopted. 

2.  Nurse's  daily  or  weekly  report. 

a.  The  best  type  is  probably  that  of  the  weekly 
report  of  the  nurses  in  the  Philadelphia 
schools. 

b.  Nurse  reports  number  and  results  of  doctor's 
examinations,  as  well  as  her  own. 

c.  Reports  should  be  summarized  weekly,  and 
printed  in  newspapers. 

d.  A  standard  classification  of  school  ailments 
should  be  used. 

e.  Simplest  classification  is,  infectious  and  non- 


22  HEALTH  WORK  IN  THE  SCHOOLS 

infectious,  using  common  names  in  alphabetical 
order.  The  former  may  be  divided  into  para- 
sitic and  infectious  diseases,  the  latter  into 
physical  defects  and  common  ailments.  Gen- 
eral divisions,  such  as  communicable  and  non- 
communicable  diseases,  are  desirable. 

3.  Annual  report  to  the  people. 

a.  Should  be  detailed,  and  yet  comprehensible  to 
the  public. 

b.  It  should  show  how  many  cases  were  found, 
how  many  cured,  improved,  found  not  needing 
treatment  by  family  physician,  and  by  what 
agencies  cared  for.  The  number,  not  cured, 
treated,  or  improved,  is  a  most  necessary  part 
of  efficient  reporting.  Adequate  reporting  in 
this  field  has  not  been  worked  out  by  any 
city. 

4.  Other  records,  notices,  reports,  exclusions,  etc., 
need  be  little  different  from  those  in  vogue.  (Rec- 
ords should  lead  to  a  frequent  health  invoice.) 

D.  Standardization. 

1.  Examinations. 

a.  Medical,  by  the  doctor  (medical  examiner)  if 
there  is  one. 

X.  Number,  7  to  10  an  hour,  say  twenty  in  a 
two-hour  day  when  there  are  no  excep- 
tional cases,  or  about  one  hundred  a 
week. 

Y.  Depending  upon  the  district  and  the 
amount  of  consultation  by  nurse  and  in- 
dividual inspection  of  referred  cases,  the 
doctor  can  examine  medically  from  1500 
to  2000  pupils  in  the  180  days  of  the  usual 
school  year.    (Minimum.) 

Z.  In  the  nurse-alone  plan,  one  nurse  can 
examine  from  800  to  1200  pupils  in  the 
year  and  do  her  other  work  of  home 
visiting  and  inspection,  varying  greatly 
with  nurses  and  communities. 

b.  Scholastic  or  anthropological. 


SCOPE  AND  ADMINISTRATION  23 

X.  Vision  tests,  about  three  minutes  each. 
Snellen's  charts.  Vision  less  than 
twenty-  twenty  referred  only  when 
there  are  bad  symptoms  of  eye-strain, 
otherwise  twenty  -  forty.  Strabismus 
(cross-eye)  should  always  be  referred  for 
treatment. 

Y.  Hearing  tests,  about  two  minutes  each — 
twenty  an  hour,  at  least.  By  nurse  or 
physical  trainer.  Stop-watch  and  whis- 
per tests.  Common  sense  about  the  only 
standard  yet. 

Z.  Height,  weight,  and  chest-expansion 
measurements,  if  required,  about  three 
minutes  each.  Of  little  value  as  usually 
taken.  Rarely  used,  even  when  well 
taken  with  pupils  stripped. 

2.  Inspections. 

a.  September  room  inspections,  —  about  forty 
an  hour,  nurse  and  doctor  working  in  separate 
rooms  with  help  of  teachers. 

b.  Nurse  and  doctor  should  be  conservative 
about  referring  cases  and  excluding  pupils, 
even  in  case  of  threatened  epidemic. 

c.  Sanitary  inspection  of  school,  standardized  by 
a  special  report  card  such  as  used  by  the 
Philadelphia  Board  of  Health  (devised  by  the 
Bureau  of  Municipal  Research) . 

d.  Nurses  and  doctors  should  be  given  schools  in 
groups,  or  along  good  lines  of  travel. 

3.  Efficient  supervision,  and  occasional  working  to- 
gether on  a  number  of  referred  cases  by  all  doctors 
and  nurses,  highly  desirable  for  purpose  of  stand- 
ardization. 

E.  Expenditures. 

1.  For  nurse:  five  and  a  half  days  a  week  (8.45  to  5 
each  school  day),  with  the  responsibility  of  inspec- 
tion, not  less  than  $70  a  month,  preferably  for 
twelve  months. 

2.  For  doctor :  two  hours  spent  in  a  single  school  each 


24  HEALTH  WORK  IN  THE  SCHOOLS 

day,  making  a  reasonable  number  of  careful  medi- 
cal examinations,  forty  hours  a  month,  about  $60 
to  $80  a  month  for  ten  months.  Where  more  is  paid 
it  is  a  question  whether  it  would  not  be  better  to  use 
the  money  for  a  good  nurse  on  full  time.  Physical 
examinations  cannot  be  carried  on  more  than  two 
or  three  hours  a  day,  because  of  the  physical  strain. 
Neither  can  physicians  be  taken  for  long  from  their 
regular  practice  each  day.  To  employ  all  for  full 
time  is  out  of  the  question.  Diminishing  returns 
bring  in  the  nurse,  often  more  competent  for  the 
simple  school  troubles  to  be  referred  to  parents  and 
family  physicians,  than  is  the  school  doctor. 

3.  Supervisor  of  the  Department  of  Hygiene :  $3000  to 
$4000  a  year,  for  full  time. 

4.  Supplies:  depending  upon  conditions,  although  cer- 
tain standard  supplies  can  be  designated.  Newark, 
New  Jersey,  has  a  good  list.  This  phase  of  the  work 
varies  greatly  in  different  cities. 

5.  Free  treatment :  Amount  of  free  treatment  is  rapidly 
increasing  in  the  larger  cities.  While  using  care, 
this  work  must  be  greatly  extended. 

N  School  medical  inspection  still  suffers  from  lack  of 
standards.  Too  often  a  narrow  view  prevails  regarding 
the  opportunities  and  responsibilities  which  the  work 
involves.  As  stated  by  Rapeer,  "the  public  demand 
for  more  attention  to  the  health  of  school  children  has 
often  been  met  by  such  temporizing  sedatives  as  the 
hiring  of  some  doctors  to  look  into  the  school  buildings 
occasionally  when  they  have  time;  having  manufac- 
turing companies  send  in  a  few  samples  of  sanitary 
drinking-fountains  or  adjustable  desks;  or  permitting 
the  park  department  to  station  a  young  woman  with  a 
see-saw  and  a  swing  on  some  school-yard  'playground' 
during  the  summer." 


SCOPE  AND  ADMINISTRATION  25 

It  is  with  the  hope  of  broadening  the  scope  of  health 
work  in  the  schools  and  contributing  to  the  standardi- 
zation of  its  methods  that  the  above  outline  has  been 
presented.  The  authors  believe  that  it  cannot  be  too 
carefully  studied,  either  by  school  boards,  superin- 
tendents, school  doctors,  or  teachers. 

Method  of  control 

This  was  one  of  the  earliest  questions  to  arise.  Medi- 
cal inspection  everywhere  began  as  an  extension  of  the 
work  of  the  already  existing  board  of  health.  However, 
the  more  the  scope  of  health  supervision  has  been  ex- 
tended, the  greater  the  tendency  has  been  to  doubt  the 
wisdom  of  this  method  of  control.  Three  leading 
objections  have  been  made :  — 

(1)  The  board  of  health  is  almost  certain  to  place 
the  emphasis  too  much  on  the  mere  prevention  of 
disease.  Insidious  defectiveness  and  the  causes  leading 
up  to  it  are  likely  to  be  overlooked; 

(2)  The  board  of  health  is  not  in  a  position  to  make 
such  adjustments  of  the  educational  processes  as  may 
be  necessary  to  minister  to  the  health  and  growth 
needs  of  the  pupil.  Attempts  to  do  so  inevitably  lead 
to  conflict  between  the  board  of  health  and  the  educa- 
tional authorities,  or  at  least  to  misunderstanding  with 
consequent  failure  to  cooperate; 

(3)  When  the  work  is  administered  by  the  non- 
educational  machinery,  the  interest  of  the  teacher  is  not , 
so  easily  enlisted.    The  bifurcated  educational  aim 
which  has  wrought  such  havoc  in  education  for  hun- 


26  HEALTH  WORK  IN  THE  SCHOOLS 

dreds  of  years  becomes  through  this  system  of  divided 
responsibility  more  strongly  intrenched  than  ever. 
r"The  school  looks  after  the  child's  mind,  the  board  of 
^  I    health  after  its   body.    Everybody  forgets    that  the 
child  is  a  psychophysical  organism  and  that  any  dual 
system  of  educational  control  is  sure  to  violate  this 
unity. 
^~\\\.  cannot  be  too  often  repeated  that  the  examination 
[      of  pupils  for  contagious  disease  is  a  relatively  unim- 
\     portant  part  of  the  health  supervision  of  schools. 
^""'"Statistics  show  that  as  a  rule  not  more  than  4  per  cent 
of  the  pupils  of  a  school  system  need  to  be  excluded  in 
one  year.  On  the  other  hand,  60  per  cent  of  the  pupils 
suffer  from  non-contagious  defects  which  need  con- 
stantly to  be  taken  into  account  by  the  educational 
authorities.1  Moreover,  the  physical  welfare  of  every 
^Kird  is  more  or  less  jeopardized  by  the  sedentary  occu- 
pations, indoor  life,  and  nervous  strain  of  the  modern 
school.jThe  task  of  the  school  department  of  health  is 


so  to  direct  the  educational  processes  that  the  child's 
native  heritage  of  vigor  and  health  may  be  fully  at- 
tained, and  his  hereditary  deficiencies,  in  so  far  as  pos- 
sible, made  good.  This  is  an  educational  problem.  It  is 
one  that  is  not  likely  to  be  effectively  dealt  with  except 
through  the  administrative  authority  of  the  school.  On 
the  other  hand,  communities  so  conservative  as  to  be 
content  with  the  earlier  type  of  "medical  inspection" 
may  very  well  leave  the  work  to  non-educational 
authorities. 

By  1911  over  three  fourths  of  the  cities  in  the  United 


SCOPE  AND  ADMINISTRATION  27 

States  supporting  health  supervision  had  lodged  the 
administration  with  the  board  of  education,  so  that 
we  may  now  consider  educational  control  one  of  the 
standard  requirements  of  health  supervision,  and  the 
best  guaranty  of  broad  and  effective  cooperation  along 
all  lines  of  child  hygiene  in  the  schools. 

It  cannot  be  denied,  however,  that  in  a  few  in- 
stances splendid  work  has  been  carried  on  in  the 
schools  by  the  board  of  health,  and  in  a  few  instances 
narrow,  unsatisfactory  work  by  the  educational  au- 
thorities. Much  depends  upon  the  man  behind  the 
system.  If  all  officers  of  public  health  had  an  adequate 
comprehension  of  the  strictly  educational  and  preven- 
tive aspects  of  hygiene  in  the  schools,  there  would  be 
less  to' choose  in  the  matter  of  control.  But  as  the  situa- 
tion now  stands,  there  can  be  no  question  that,  gener- 
ally speaking,  the  health  supervision  of  schools  in  this 
country  ought  to  be  conducted  by  educational  depart- 
ments of  health.  There  should  be  such  departments  in 
every  city  school  system,  in  every  county  also  for  the 
benefit  of  rural  and  town  schools,  and  above  all  a  State 
department  for  the  coordination  and  standardization 
of  the  work. 

Division  of  power 

Granting  that  such  a  department  of  health  exists, 
what  relations  shall  it  sustain  to  the  superintendent 
and  to  the  teachers?  Shall  it  act  only  in  an  advisory 
capacity,  or  may  we  safely  charge  it  with  a  certain 
amount  of  administrative  authority  ?  To  be  concrete, 


28  HEALTH  WORK  IN  THE  SCHOOLS 

let  us  suppose  that  the  health  department  decides  that 
a  given  pupil  cannot  safely  attend  school  more  than 
three  hours  per  day.  Let  us  suppose  also  that  the 
superintendent  of  schools  and  the  child's  teacher  dis- 
agree with  this  opinion.  In  such  a  case  whose  judg- 
ment should  legally  prevail?  Similar  questions  are 
likely  to  arise  occasionally  in  regard  to  excusing  a  pupil 
from  gymnastics,  and  in  regard  to  the  segregation  of 
children  in  special  classes  for  open-air  treatment,  etc. 

It  seems  clear  that  the  decisions  of  the  department 
of  health  should  at  least  not  be  subject  to  reversal  by 
any  other  authority  than  the  board  of  education  or 
superintendent,  and  it  is  an  open  question  whether  the 
superintendent  should  have  this  power.  School  hy- 
giene is  a  technical  field,  where  only  expert  opinion  is 
reliable.  Because  the  hygienic  affairs  of  the  school 
require  expert  direction,  the  board  of  education  creates 
the  health  department  for  this  purpose,  just  as  it 
creates  other  offices  for  the  supervision  of  instruction. 
The  expertness  of  the  department  should,  therefore,  be 
respected.  Deficiency  of  a  child's  blood  in  oxygen- 
carrying  material,  or  a  retarded  condition  of  his 
skeletal  development  as  indicated  by  the  Roentgen 
rays,  or  an  excessive  predisposition  to  fatigue,  —  these 
are  matters  which  call  for  expert  diagnosis  and  expert 
treatment  no  less  than  measles  or  diphtheria. 

Practically,  however,  there  ought  to  be  few  cases  of 
conflict,  wherever  the  ultimate  control  is  vested.  The 
sensible  medical  director  will  find  that  he  must  work 
through  the  superintendent  and  the  teachers.    If  he 


SCOPE  AND  ADMINISTRATION  29 

conscientiously  gathers  his  data  and  cautiously  bases 
his  recommendations  upon  a  reliable  body  of  ascer- 
tained fact,  and  if  he  presents  these  recommendations 
with  reason]/Sle  tact,  there  will  ordinarily  be  no  diffi- 
culty in  securing  favorable  action  on  the  part  of  super- 
intendent and  board  of  education.  On  the  other  hand, 
if  the  medical  director  is  incautious  or  unscientific  in 
his  recommendations,  if  he  is  intemperate  in  his  con- 
demnation of  current  school  practices,  or  if  he  meddles 
unduly  with  the  work  of  instruction,  the  efficiency  of 
his  department  is  certain  to  be  impaired.  TJie  school 
department  of  health  should  have  no  place  for  the  man 
or  woman  who  is  temperamentally  unable  or  unwilling 
to  cooperate  harmoniously  with  other  educational 
authorities. 

Records 

The  practical  value  of  the  work  of  the  department 
of  school  hygiene  depends  intimately  upon  its  book- 
keeping methods.  Too  often  the  methods  in  use  fail  to 
give  us  the  information  we  need.  The  following  are 
some  of  the  faults  which  have  helped  to  render  the 
statistics  of  medical  inspection  confusing,  contradic- 
tory, and  sometimes  misleading:  — 

(1)  Stating  the  absolute  number  of  defects  found 
without  indicating  the  number  of  children  furnishing 
them.  What  a  community  wants  to  know  is  not  that 
School  A  has  fewer  defective  eyes  than  School  B,  but 
the  relative  percentage  of  defective  eyes  in  the  two 
schools. 


30  HEALTH  WORK  IN  THE  SCHOOLS 

(2)  We  should  also  be  informed  what  the  percentage 
is  a  percentage  of;  whether  of  total  enrollment,  or  of  a 
representative  portion  of  the  enrollment,  or  of  a  por- 
tion specially  selected  by  teachers  or  nurses  for  sus- 
pected defects. 

(3)  Another  common  mistake  is  to  fail  to  distin- 
guish between  the  number  of  examinations  made  and 
the  number  of  children  examined.  Since  many  chil- 
dren receive  frequent  examinations,  the  two  sets  of 
facts  do  not  even  approximately  correspond. 

(4)  Still  more  serious  is  the  failure  of  the  general 
report  to  differentiate  sufficiently  among  kinds  of 
defects.  The  common  and  the  extremely  rare,  primary 
and  secondary,  curable  and  incurable,  chronic  and 
temporary,  the  very  grave  and  the  unimportant  are 
all  lumped  together.  This  leaves  us  without  data  for 
arriving  at  reliable  conclusions  as  to  the  influence  of 
the  various  kinds  of  defectiveness  upon  mental  devel- 
opment or  upon  the  child's  school  progress.  In  such  an 
ill-considered  system  of  records,  a  slightly  decayed 
temporary  tooth,  about  to  be  replaced  by  a  permanent 
one,  counts  for  just  as  much  as  an  extreme  case  of 
myopic  astigmatism  or  a  discharging  ear.  Hunchbacks 
and  boils  are  not  distinguished.  Again,  one  defect,  by 
counting  all  its  symptoms,  becomes  three  or  four.  By 
one  system  of  records  a  child  may  be  accredited  with 
two  defects  and  by  another  system  with  eight  or  ten, 
without  necessarily  implying  any  essential  difference 
in  the  expertness  of  the  examinations  themselves. 
Defects  which  are  plainly  temporary  should  be  care- 


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32  HEALTH  WORK  IN  THE  SCHOOLS 

fully  distinguished  in  reports  from  those  which  are 
chronic;  likewise  the  curable  from  the  incurable. 
These  factors  help  to  determine  what  action  the 
school  shall  take  regarding  notification  of  parents,  and 
in  adapting  the  work  of  the  school  to  the  child.  What 
we  most  want  to  know  is  how  the  many  kinds  of  defec- 
tiveness are  related  to  each  other,  to  school  progress, 
to  age,  and  to  mentality. 

(5)  The  pupil's  individual  record  card  is  not  less 
important  than  the  general  report,  and  is  subject  to 
much  the  same  faults.  It  should  be  explicit  and  not 
vague.  In  recording  a  defective  ear,  for  example,  it 
should  distinguish  between  partial  deafness  and  a  dis- 
charge. Eyes  should  be  recorded  separately,  and  ob- 
jective tests  for  eye-strain  should  be  listed,  apart  from 
general  symptoms.  If  glasses  are  worn,  the  fact 
should  be  noted,  together  with  the  date  of  their  pur- 
chase and  with  record  of  the  visual  acuity  with  them 
on.  Squint  should  be  designated  explicitly.  Explicit- 
ness  should  be  the  rule.  At  the  same  time  the  record 
should  not  be  encumbered  and  rendered  misleading  by 
the  over-conscientious  insertion  of  data  pertaining  to 
slight  and  unimportant  ailments.     (See  page  31.) 

(6)  Having  an  ideal  individual  record  card,  what 
shall  we  do  with  it?  Some  medical  directors  bury  their 
work  alive  by  filing  it  away  in  a  distant  central  office. 
If  a  teacher  wants  to  know  the  facts  about  the  health 
of  one  of  her  pupils,  she  will  have  to  make  a  trip  to  this 
office.  Needless  to  say,  under  this  kind  of  system, 
teachers  and  supervisors  cannot  be  expected  to  know 


SCOPE  AND  ADMINISTRATION  33 

much  about  the  health  conditions  of  their  children. 
The  card  should  always  accompany  the  pupil  through- 
out his  course  by  being  transferred  to  each  of  his  suc- 
cessive teachers.  If  the  central  office  can  afford  to  have 
a  copy,  well  and  good.  If  there  is  only  one  card,  there 
ought  to  be  no  question  as  to  where  it  belongs. 

Schools  and  publicity 

The  school  does  not  always  court  full  publicity. 
School  reports  give  little  information  as  to  the  real 
efficiency  of  a  school.  They  are  too  likely  to  give  all 
the  lights  and  none  of  the  shadows.  They  are  some- 
times shameless  advertisements  of  the  superintendent 
or  the  school  board.  The  private  individual  who  shows 
an  interest  in  facts  not  officially  revealed  may  be 
accused  of  enmity  and  suspected  of  acting  from  per- 
sonal motives.  The  following  are  some  of  the  matters 
concerning  which  American  school  authorities  do  not 
give  sufficient  information:  — 

(1)  The  amount  of  retardation  and  elimination  in 
all  the  grades. 

(2)  The  intra-school  and  extra-school  causes  of  such 
retardation  and  elimination  as  exist. 

(3)  The  efficiency  of  the  school,  as  measured  by  its 
actual  grade  performances.  Here,  instead  of  any  at- 
tempt at  stating  objective  facts,  the  board  of  education 
may  lay  claim  to  having  the  "most  efficient  school 
system  in  the  State."  In  the  West  this  is  changed  to 
the  "best  in  the  United  States." 

(4)  The  hygienic  imperfections  of  its  school  build- 


34  HEALTH  WORK  IN  THE  SCHOOLS 

ings  are  seldom  plainly  and  explicitly  stated.  When 
the  evil  is  too  crying  to  permit  absolute  silence,  such 
statements  as  are  allowed  to  appear  lose  all  flavor  of 
truthfulness  either  through  vagueness  or  fragmentari- 
ness.  The  schoolroom  which  has  one  third  the  stand- 
ard amount  of  light,  and  which  investigation  would 
probably  show  to  have  an  excessive  amount  of  eye 
defect  among  its  pupils,  will  at  most  be  reported  as 
"somewhat  deficient  in  light/'  etc.  School  authorities 
do  not  tell  us  what  school  buildings  are  supplied  with 
air  dryer  than  the  air  of  Sahara.  They  do  not  tell  us 
anything  about  the  relation  of  colds,  influenza,  etc., 
to  the  ventilation  and  warming  of  school  buildings, 
nor  do  they  enlighten  us  very  materially  in  regard  to 
the  methods  of  sanitation  which  they  employ. 

(5)  Lastly,  as  we  have  already  seen,  they  tell  the 
public  very  little  about  the  physical  conditions  of  the 
children,  and  still  less  about  the  relation  of  one  defect 
to  others  or  to  school  and  social  environment. 

Not  even  schools  can  remain  permanently  exempt 
from  publicity.  For  the  very  reason  that  public  educa- 
tion is  the  institution  of  most  vital  concern  to  the 
entire  population,  those  who  control  it  are  morally 
obligated  to  afford  publicity  of  all  the  facts  which  con- 
cern it.  The  more  intimate  or  unpleasant  the  facts  the 
deeper  is  this  obligation.  Sooner  or  later,  this  ideal  is 
certain  to  take  possession  of  us.  The  campaign  for  pub- 
licity in  matters  of  public  concern  will  not  stop  at  the 
threshold  of  the  school,  and  we  shall  do  well  to  prepare 


SCOPE  AND  ADMINISTRATION  35 

ourselves  for  it  by  studying  a  little  the  methods  of 
scientific  management. 

REFERENCES 

(Only  references  relating  to  the  scope  and  administration  of  medi- 
cal inspection  are  included  here.) 

*1.  Allen,  W.  H.:  Civics  and  Health.  (Chapter  xxx,  "School  and 
Health  Reports";  chapter  xxxiii,  " Organization  of  School 
Hygiene  in  New  York  City";  chapter  xxix,  "  Official  Machin- 
ery for  Enforcing  Health  Rights.") 

*2.  Ayres,  Leonard  P.:  Medical  Inspection  Legislation.  1911,  pp. 
54.  Bull.  99,  Russell  Sage  Foundation,  New  York. 

3.  Cornell,  Walter  S. :  "Good  and  Bad  Forms  of  Record  Keeping." 
Proc.  Am.  Sch.  Hyg.  Assoc,  1911,  pp.  65-72. 

4.  Cornell,  Walter  S.:  "The  Need  of  Improved  Records  of  .the 
Physical  Conditions  of  Children."  Psychological  Clinic,  1909, 
pp.  161-63. 

5.  Cornell,  Walter  S. :  The  Health  and  Medical  Inspection  of  School 
Children,  1912.   (Chapter  i.) 

6.  Crowley,  Dr.  Ralph  H.:  The  Hygiene  of  the  School  Child,  1909. 
(Chapter  v,  "Medical  Inspection  of  the  Child  in  the  School. 
The  Parent  and  the  State.") 

*7.  Gulick  and  Ayres:  The  Medical  Inspection  of  Schools.  1913. 
(Chapter  vi,  "Making  Medical  Inspection  Effective";  chapter 
x,  "Controlling  Authorities";  chap,  xi,  "Legal  Provisions.") 

*8.  Hoag,  E.  B.:  The  Health  Index  of  Children.  1910,  pp.  188. 
(Chapter  xn,  "An  Office  System  for  School  Health  Depart- 
ments"; chapter  xin,  "  A  General  Plan  for  Health  Supervision 
in  Schools";  chapter  xiv,  "Some  Details  of  the  Physician's 
Examinations";  chapter  xv,  "The  Cooperation  of  School 
Health  Departments  with  Other  Agencies.") 

*9.  Hogarth,  Dr.  A.  N. :  The  Medical  Inspection  of  Schools.  1909. 
(Chapter  vn,  "  The  General  Principles  and  Aims  of  Medical 
Inspection";  chapter  vn,  "The  Organization  of  a  Central 
Department";  chapter  ix,  "Local  Organization";  chapter 
xiii,  "Administrative  Routine";  chapter  xvi,  "Common 
Diseases  affecting  School  Life.") 

10.  Hope,  Dr.  E.  S. :  "  Correlation  of  the  School  Medical  Service 
and  the  Health  Medical  Service."  In  Kelynack's  Medical  In- 
spection of  Schools,  chapter  i,  pp.  1-10. 

11.  Howerth,  Dr.  W.  J.:  "  Organization  and  Administration  of  the 
Medical  Examination  of  Scholars."  In  Kelynack's  Medical 
Inspection  of  Schools,  chapter  in,  pp.  34-62. 

12.  Mackenzie,  Dr.  W.  Leslie:  The  Medical  Inspection  of  School 
Children.  1909.   (Chapters  i  to  vi.) 

13.  Porter,  Charles:  School  Hygiene  and  the  Laws  of  Health.  Lon- 


36  HEALTH  WORK  IN  THE  SCHOOLS 

don,  1908.  (Chapter  xxn,  "  The  Medical  Inspection  of  Schools 
and  School  Children.") 
*14.  Rapeer,    Louis    W.:     School    Health  Administration.     1913, 
pp.  360. 

15.  Snedden,  David  S.:  "Problems  of  Health  Supervision  in  the 
Schools  of  Massachusetts."  Proc.  Am.  Sch.  Hyg.  Assoc,  1912, 
pp.  18-26.  t 

16.  Storey,  Dr.  Thomas  A.:  "Medical  Inspection  in  Schools  from 
the  Standpoint  of  the  Educator."  Medical  Review  of  Reviews, 
July,  1912. 

*17.  Newmayer,  Dr.  S.  W.:  Medical  and  Sanitary  Inspection   of 
Schools.   1913,  pp.  318.    (Part  I.) 


CHAPTER  III 

PLANS  FOR  ORGANIZATION  FOR  HEALTH  WORK 

State  versus  local  control 

Although  the  development  of  health  work  in  the 
schools  has  been  very  rapid,  much  remains  to  be  done 
to  make  it  as  effective  as  it  ought  to  be.  Its  greatest 
weakness  lies  in  the  absence  of  standardized  direction 
and  procedure.  With  regard  to  it  the  most  divergent 
beliefs  and  practices  prevail. 

The  logical  place  for  the  oversight  of  such  work  is 
the  State,  though  almost  everywhere  in  the  United 
States  city  action  has  preceded  state  action.  For  the 
State  to  assume  general  responsibility  for  school  health 
work  would  only  be  in  line  with  other  extensions  of 
the  State's  interest  in  the  welfare  of  its  children,  in- 
cluding state  laws  for  vocational  education,  state  uni- 
formity in  textbooks  and  courses  of  study,  state  sup- 
port for  secondary  schools,  etc. 

State  action  in  matters  relating  to  school  hygiene 
is  desirable  for  two  important  reasons:  (1)  it  sets 
standards  for  the  conduct  of  the  work  which  insure 
that  it  will  be,  on  the  whole,  much  better  done  than 
is  the  case  when  each  community  is  left  to  work  out 
its  own  methods  blindly;  and  (2)  it  is  the  best  and  only 
guaranty  that  backward  communities  will  not  neglect 


38  HEALTH  WORK  IN  THE  SCHOOLS 

such  matters  altogether.  In  the  absence  of  manda- 
tory state  laws,  rural  schools  almost  never  enjoy  the 
requisite  hygienic  oversight,  either  as  regards  school 
buildings  or  the  children  themselves. 

By  1912  some  twenty  States  had  passed  laws  pro- 
viding for  the  medical  inspection  of  schools,  but  in 
only  nine  cases  are  the  laws  mandatory.  Even  where 
the  law  is  mandatory,  the  details  of  method  and  pro- 
cedure are  too  often  left  to  the  initiative  of  the  city, 
county,  or  school  district,  so  that  most  of  the  benefits 
which  would  accrue  from  responsible  state  depart- 
ments of  health  supervision  are  not  enjoyed. 

Examples  of  state  departments 

In  August,  1912,  the  State  of  Minnesota  organized, 
for  the  first  time  in  the  United  States,  a  "State  Divi- 
sion of  Health  Supervision  of  Schools. "  The  work  was 
undertaken  by  the  State  Board  of  Health,  with  'the 
cooperation  of  the  State  Department  of  Public  In- 
struction. 

A  Director  of  School  Hygiene  was  appointed  whose 
duties  were  as  follows :  — 

(1)  To  visit  towns  and  cities  desiring  aid  in  the 
promotion  of  school  health  work. 

(2)  To  maintain  a  clearing-house  of  information  in 
matters  pertaining  to  school  and  child  hygiene,  at  the 
offices  of  the  State  Board  of  Health. 

(3)  To  offer  lectures  on  general  topics  of  school  and 
child  hygiene  to  teachers'  institutes,  and  other  or- 
ganizations desiring  them. 


ORGANIZATION  IN  THE  SCHOOLS  39 

(4)  To  conduct  short  courses  on  child  hygiene  at 
each  of  the  State  Normal  Schools. 

(5)  To  carry  on  investigations  in  matters  pertain- 
ing to  school  and  child  hygiene. 

(6)  To  publish  and  circulate  information  to  schools, 
pupils,  and  parents  on  subjects  relating  to  the  pro- 
motion of  health  among  school  children. 

(7)  To  maintain  an  exhibit  of  school  hygiene,  at 
the  offices  of  the  State  Board  of  Health. 

(8)  To  maintain  a  bureau  of  information  in  respect 
to  available  school  medical  officers  and  school  nurses. 

The  general  program  of  the  director  at  each  place 
visited  was  as  follows :  — 

(1)  A  general  meeting  with  all  the  teachers  of  the 
local  school  system,  at  which  were  explained  methods 
for  the  physical  observation  of  school  children.  At 
these  meetings  practical  demonstrations  (or  school 
clinics)  were  given,  with  one  or  more  grades  of  school 
children  present,  usually  a  fourth  or  fifth  grade.  (See 
chapter  vi  for  a  stenographic  report  of  one  such  clinic 
held.) 

(2)  Individual  demonstrations  in  various  grades 
in  different  schools. 

(3)  Examination  of  special  cases,  including  mentally 
defective  children. 

(4)  A  second  meeting  with  all  the  teachers  for  the 
purpose  of  discussing  the  results  of  the  examinations. 

(5)  An  open  meeting  devoted  to  the  interests  of 
parents  of  school  children. 


40  HEALTH  WORK  IN  THE  SCHOOLS 

(6)  Sanitary  inspection  of  school  buildings  and 
premises. 

(7)  Organization  of  the  study  of  mentally  deficient 
children. 

(8)  Recommendations  for  health  promotion  ad- 
dressed to  the  board  of  education,  and  adapted  to  the 
conditions  discovered. 

The  University  of  Virginia,  in  cooperation  with  the 
State  Board  of  Health  and  the  State  Department  of 
Public  Instruction,  has  organized  a  plan  somewhat 
similar  to  that  of  Minnesota,  and  it  is  safe  to  say  that 
in  a  comparatively  short  time  state  organization  and 
standardization  of  school  and  child  hygiene  will  be 
undertaken  by  most  of  the  progressive  States  of  the 
Union. 

However  maintained,  provided  only  the  work  be 
vigorously  and  sanely  prosecuted,  the  State  Depart- 
ment of  Child  Hygiene  is  sure  to  be  of  incalculable 
benefit.  It  hastens  the  progress  of  health  supervision 
not  only  by  persuading  school  authorities  to  establish 
it,  but  also  by  standardizing  the  procedure  so  as  to 
insure  efficiency.  By  influencing  legal  and  educational 
control  it  would  in  many  cases  save  years  of  needless 
and  discouraging  experimentation.  Such  a  depart- 
ment should  organize  and  prosecute  State-wide  in- 
vestigations of  child  hygiene,  in  the  broadest  sense, 
including  infant  mortality,  mental  retardation,  juve- 
nile criminality,  the  hygiene  of  mental  activity,  etc. 

In  the  organization  of  such  departments  it  is  de- 


ORGANIZATION  IN  THE  SCHOOLS  41 

sirable  that  the  work  be  broadly  conceived,  so  as  to 
bring  within  its  scope  as  many  aspects  of  child  hygiene 
and  child  welfare  as  possible.  Research  should  be  vigor- 
ously prosecuted  along  all  lines  of  mental  and  physical 
deviation,  and  should  look  especially  toward  methods 
of  amelioration  and  prevention.  There  should  be  sub- 
departments  for  the  hygiene  of  instruction,  mental 
retardation,  preventive  mental  hygiene,  etc1.,  each 
with  specially  trained  assistants  in  charge. 

City  organization  of  school  health  supervision 

Most  of  the  larger  cities  of  the  country  have  taken 
up  the  work  in  some  fashion  or  other,  without  refer- 
ence to  state  action.  By  1898,  Boston,  Chicago,  New 
York,  and  Philadelphia  had  inaugurated  systems  of 
medical  inspection.  About  90  cities  had  followed  the 
example  by  1907,  337  by  1910,  and  nearly  500  by 
1913. 

This  wave  of  activity  has  resulted  in  (1)  a  few 
well-developed  City  Departments  of  School  Hygiene; 

(2)  many    partially    developed    undertakings;    and 

(3)  a  desire,  on  the  part  of  many  smaller  cities,  to 
undertake  some  kind  of  health  supervision  in  an 
inexpensive  way,  without  the  employment  of  school 
physicians. 

In  order  to  indicate  some  of  the  best  plans  for  health 
work  in  schools,  and  in  a  measure  to  furnish  standards 
which  may  be  successfully  put  into  operation,  three 
distinct  plans  of  organization  for  school  health  work 
are  here  set  forth,  devised  to  meet  varying  conditions, 


42  HEALTH  WORK  IN  THE  SCHOOLS 

such  as  are  sure  to  exist  in  different  places.  The  three 
plans  are  as  follows :  — 

(1)  Organization  with  one  or  more  medical  officers, 
and  a  nurse  or  nurses. 

(2)  Organization  with  a  school  nurse  or  nurses  only. 

(3)  Organization  by  the  employment  of  a  simple 
non-technical  health  survey  on  the  part  of  the  teachers 
only.  Such  a  survey  is  provided  by  a  series  of  ques- 
tions based  upon  ordinary  observations  of  physical 
and  mental  conditions. 

In  the  present  chapter,  Plan  (1)  is  set  forth  in  a 
general  way,  and  in  the  appendix  the  organization  in 
five  typical  cities  is  described.  Plan  (2),  supervision 
by  nurses  only,  is  described  in  chapter  iv;  and  Plan 
(3),  health  grading  by  teachers^  in  chapters  v  and  vi. 

Plan  (1):  Physicians  and  Nurses 

A  physician  should  be  selected  who  has  some  special 
interest  in  and  adaptability  for  work  with  school  chil- 
dren. In  addition  to  this  he  should  have  made  some 
special  study  of  school  hygiene,  since  medical  colleges 
unfortunately  do  not  usually  include  such  courses  in 
their  curricula. 

Whether  the  medical  officer  shall  give  part  or  all 
of  his  time  to  this  work  will  depend  largely  upon  the 
duties  required  of  him.  In  communities  where  the 
number  of  school  pupils  does  not  exceed  4000  to  6000, 
it  is  possible  for  one  well-trained  school  doctor  to 
render  satisfactory  service  by  devoting  one  half  of  his 
time  to  the  work,  provided  he  has  as  assistants  at 


ORGANIZATION  IN  THE  SCHOOLS  43 

least  two  well-trained  nurses  who  possess  special 
adaptability  for  this  kind  of  work. 

In  places  of  from  8,000  to  12,000  school  population, 
it  is  best  to  have  one  physician  give  his  entire  time, 
and  an  assistant  physician  give  half-time.  In  such 
places  there  should  be  employed  at  least  three  or  four 
school  nurses. 

In  places  where  the  school  pupils  exceed  12,000, 
one  may  estimate  an  additional  half-time  school  medi- 
cal officer  and  from  one  to  two  full-time  school  nurses 
for  each  6,000  increase  in  the  number  of  pupils.  For 
a  city  the  size  of  Los  Angeles  or  Indianapolis,  this 
would  mean  from  twelve  to  twenty  school  nurses. 

Many  will  say  that  this  is  an  inadequate  force  for 
so  large  a  number  of  pupils,  and  gauged  by  absolute 
perfection  this  may  be  true.  But  it  must  be  remem- 
bered that  school  systems  have  many  practical  adjust- 
ments to  make,  and  that  this  is  actually  a  larger  force 
than  schools  now  employ. 

The  plan  presupposes  preliminary  examinations  on 
the  part  of  nurses  and  teachers,  after  the  manner  sug- 
gested in  chapter  v.  This  method  relieves  the  medical 
officers  from  much  purely  routine  examination  of 
practically  normal  children,  and  allows  them  to  con- 
centrate their  attention  on  children  really  needing 
expert  services.  With  the  methods  employed  at  pres- 
ent, school  doctors  waste  a  great  amount  of  time  doing 
purely  inexpert  work,  which  might  far  better  be  done 
by  teachers  and  nurses.  At  present  most  cities  are  in 
this  way  paying  experts  for  inexpert  service. 


44  HEALTH  WORK  IN  THE  SCHOOLS 

When  a  city  is  large  enough  to  require  the  services 
of  several  medical  officers  in  the  schools,  the  follow- 
ing plan  is  suggested  and  recommended  as  the  most 
efficient  one:  — 

There  should  be  one  general  director,  giving  his 
entire  time  to  the  work.  Instead  of  employing  several 
half-time  physicians  as  his  assistants,  fewer  men  on 
whole  time  are  recommended.  The  organization  might 
be  made  up  as  here  indicated  for  a  city  of,  say,  60,000 
school  children :  — 

One  Chief  Health  Director. 

One  General  Medical  Officer. 

One  eye,  ear,  nose,  and  throat  specialist. 

One  specialist  in  mental  and  nervous  diseases,  who 
is  also  experienced  in  psychological  methods. 

One  emergency  physician. 

One  woman  physician  in  charge  of  high-school  girls. 

One  dental  specialist. 

This  number  (seven)  would  take  the  place  of  the 
twelve  physicians  under  the  usual  plan  in  vogue,  and, 
with  appropriate  increase  in  the  number  of  school 
nurses,  would  result  in  better  work  in  every  respect. 

Such  a  plan  would  require  a  central  office  of  several 
rooms;  namely,  one  general  reception-room;  one  pri- 
vate office  for  the  director;  one  examining-room ;  one 
laboratory  equipped  with  medical  and  psychological 
apparatus.  There  should  be  a  dental  and  medical 
clinic,  either  in  connection  with  the  schools  (and  this 
is  preferable),  or,  if  this  seems  impossible  to  arrange, 
then  in  connection  with  some  other  organization. 


ORGANIZATION  IN  THE  SCHOOLS  45 

With  this  plan  in  operation,  parents  of  defective 
children  would  have  the  opportunity  of  taking  their 
children  to  the  central  office  for  special  examinations. 
The  different  specialists  would  keep  office  hours  on 
different  days  of  the  week,  and  could  thus  give  careful 
and  deliberate  attention  to  such  school  children  as  re- 
quired it.  From  this  office,  cards  of  admission  to  the 
medical  or  dental  clinics  could  be  issued  to  those  en- 
titled to  them.  One  special  school  nurse  should  be 
assigned  for  duty  at  the  central  office,  whose  duty  it 
would  be  to  keep  the  records  and  assist  the  physician 
in  the  examination.* 

The  cost  7>f  health  supervision  by  Plan  (l) 

The  expense  of  a  system  providing  for  competent 
health  supervision  of  about  50,000  school  children 
would  probably  fall  somewhere  between  $18,000  and 
$25,000  annually  for  equipment  and  for  salaries  of 
physicians  and  nurses.  If  the  scope  of  the  work  is 
enlarged  by  the  addition  of  one  or  more  psychologists, 
and  by  extensive  use  of  clinics  for  free  treatment,  the 
cost  would  be  proportionately  greater. 

The  importance  of  adequate  salaries  deserves  special 
emphasis.  We  frequently  hear  of  a  medical  officer 
giving   half-time,   examining   thousands   of   children 

1  For  the  benefit  of  those  specially  interested  in  school  health 
organization,  the  plans  of  health  supervision  in  five  representative 
cities  of  the  United  States  are  presented,  in  some  detail,  in  Appen- 
dix I.  Special  attention  is  called  to  the  organization  in  Milwaukee. 
See  also  Rapier's  School  Health  Administration  for  work  in  twenty- 
five  representative  cities. 


46  HEALTH  WORK  IN  THE  SCHOOLS 

in  a  school  year,  and  receiving  for  his  services  a  pit- 
tance of  $200.  It  should  go  without  saying  that  what- 
ever public  service  is  worth  having  is  worth  paying 
for.  Until  salaries  of  health  supervisors  are  placed  on 
a  better  footing  it  is  useless  to  expect  the  kind  of  serv- 
ice that  is  most  needed. 

Costs  are  large  or  small  relatively  to  other  costs. 
The  annual  money  loss  to  the  people  of  the  United 
States  due  to  their  ignorance  and  carelessness  of  the 
laws  of  hygiene  has  been  conservatively  estimated 
at  not  less  than  $2,000,000,000.  It  is  probably  a  good 
deal  more  than  that.  The  annual  cost  from  tuberculo- 
sis alone  is  not  less  than  $500,000,000.  Our  calcula- 
tion takes  no  account  of  impaired  efficiency  due  to 
alcoholism  or  other  vicious  habits,  undue  fatigue, 
minor  ailments,  and  general  lack  of  expert  direction 
of  the  human  machine,  nor  does  it  try  to  place  a  money 
value  upon  grief  and  moral  suffering  resulting  from 
preventable  sickness  or  death. 

If  the  kind  of  health  supervision  here  suggested 
were  established  in  every  city  and  county  of  every 
State  in  the  Union,  the  annual  cost  would  not  exceed 
$5,000,000  to  $10,000,000,  or  less  than  half  of  one  per 
cent  of  our  annual  loss  from  sickness,  physical  in- 
efficiency, and  premature  death.  In  passing  we  may 
also  note  that  this  sum  is  about  equal  to  the  cost 
of  one  warship;  to  one  sixtieth  of  the  money  cost  of 
the  alcoholic  beverages  consumed  annually  in  the 
United  States;  or  to  one  fortieth  of  our  annual  ex- 
penditure for  tobacco. 


ORGANIZATION  IN  THE  SCHOOLS  47 

It  is,  of  course,  not  claimed  that  child  hygiene  in 
the  schools  can  prevent  all  of  the  losses  due  to  pre- 
ventable sickness,  but  there  can  be  no  doubt  that  it 
would  save  many  times  more  than  half  of  one  per 
cent  of  them.  Through  education  its  effects  would 
become  cumulative.  It  is  not  unreasonable  to  suppose 
that  in  the  long  run  the  annual  returns  would  amount 
to  fifty  times  the  annual  cost.  Compared  to  other  ed- 
ucational expenditures  the  cost  cannot  be  consid- 
ered large.  The  elementary  and  secondary  schools 
of  the  United  States  are  supported  by  an  annual  ex- 
pense of  nearly  $450,000,000.  If  ideal  health  super- 
vision were  made  universal,  this  amount  would  have 
to  be  increased  only  to  the  extent  of  about  one  or 
two  per  cent.  Stating  it  in  another  way,  the  public  at 
present  is  willing  to  expend,  and  does  expend  on  an 
average,  about  $35  annually  in  the  mental  and  moral 
education  of  one  of  its  children.  If  it  also  undertook 
the  hygienic  supervision  of  the  child's  growth  and 
development  the  amount  would  be  about  $35.50. 
Health  supervision  for  the  child's  whole  elementary 
school  life  would  be  about  $3  to  $4.  A  progressive 
city  of  300,000  people  and  45,000  school  enrollment 
expends  over  $125,000  for  salaries  of  superintendents, 
assistant  superintendents,  and  supervising  principals, 
who  themselves  do  no  teaching.  It  could  at  least  afford 
to  expend  one  fifth  of  this  amount  for  health  super- 
vision and  hygiene  investigations. 


CHAPTER  IV 

THE  SCHOOL  NURSE:  INCLUDING  SUGGESTIONS  FOR 

HEALTH    SUPERVISION    BY    THE    "NURSE 

ALONE"  PLAN 

Spread  of  school  nursing 

One  of  the  latest  and  best  additions  to  our  educa- 
tional forces  is  the  school  nurse.  Perhaps  no  other 
educational  movement,  not  even  excepting  medical 
inspection  itself,  has  spread  with  more  rapidity  or 
has  met  with  such  unanimity  of  support. 

School  nursing  had  its  beginning  in  England.  In 
1894  a  district  nurse  was  asked  to  visit  a  London 
school  attended  by  poor  children,  to  help  to  relieve 
their  ills.  In  1898,  a  voluntary  "School  Nurses'  So- 
ciety" was  founded  with  the  idea  of  extending  the 
work,  as  a  result  of  which  three  nurses  were  appointed. 
In  1904,  when  the  work  of  the  London  School  Board 
was  taken  over  by  the  London  County  Council,  and 
reorganized,  the  number  of  nurses  was  increased  to 
12,  and  still  later  to  50.  Other  cities  of  England, 
large  and  small,  speedily  followed  the  example  of 
London,  and  school  nursing  is  now  being  carried  into 
the  rural  districts. 

In  the  United  States  it  was  not  until  1903  that  the 
movement  can  really  be  said  to  have  begun.  In  that 
year  New  York  appropriated  $30,000  for  the  purpose, 


THE  SCHOOL  NURSE  49 

and  appointed  27  nurses  to  assist  the  Board  of  Health 
in  the  medical  inspection  of  schools.  By  1907,  eight 
cities  in  the  country  had  school  nurses,  and  by  1910 
nearly  eighty.  Of  these  71  per  cent  are  located  in  the 
Northern  States.  Boston,  with  its  force  of  25  school 
nurses,  supported  at  an  annual  expense  of  $25,000, 
is  an  excellent  illustration  of  what  progressive  Ameri- 
can cities  are  doing  in  this  line.  New  York  City,  at 
the  time  this  is  written,  has  176.  In  all  parts  of  the 
country  the  number  is  increasing  with  great  rapidity. 
Special  provision  for  the  employment  of  school  nurses 
is  now  made  in  the  medical  inspection  laws  of  several 
States. 

Nurses  necessary  for  follow-up  work 

Medical  inspection  rendered  the  school  nurse  in- 
evitable. When  the  doctor  was  brought  into  the 
schools,  he  faced  a  new  and  tremendously  difficult 
situation.  The  school  doctor's  helplessness  has  been 
vividly  described  by  Dr.  Hay  ward,  of  England,  as 
follows :  — 

As  a  doctor  I  felt  quite  stranded  in  the  strange  atmosphere 
of  an  elementary  school,  coming  into  contact,  not  so  much 
with  actual  illness,  as  with  the  primary  conditions  which 
produce  and  foster  it.  Dirt,  neglect,  improper  feeding,  mal- 
nutrition, insufficient  clothing,  suppurating  ears,  defective 
sight,  verminous  conditions,  the  impossibility  of  getting 
adequate  information  from  the  children  or  a  knowledge  of 
their  home  conditions ;  and  nobody  to  whom  one  could  give 
directions  or  who  could  help  in  examining  the  children.  The 
only  means  of  approaching  the  parents  was  to  send  an  official 
notice  that  such  or  such  a  condition  required  treatment.  My 
duties  began  and  ceased  with  endless  notifications,  and  there 
it  all  stopped,  as  very  little  notice  was  taken  of  them. 


50 


HEALTH  WORK  IN  THE  SCHOOLS 


This  has  been  the  experience  everywhere.  Without 
an  effective  follow-up  service,  conducted  by  visiting 
nurses,  medical  inspection  is  ineffective.  Until  1908, 
New  York  City  relied  upon  a  postal  card  notification 
sent  to  parents  of  defective  children,  and  was  able  to 
secure  action  in  only  6  per  cent  of  the  cases  where 
treatment  was  recommended.  Immediately  upon 
placing  the  follow-up  service  in  the  hands  of  school 
nurses  the  percentage  increased  to  84.  This  brought 
treatment  to  nearly  200,000  additional  pupils.  The 
following  chart  shows  the  difference  in  the  results 


Eyes  Tonsils  Adenoids 

I  I   Before  employing  nurses 

^^    After 

FIG.  1 
Percentage  of  recommendations  acted  on  in  Philadelphia. 


THE  SCHOOL  NURSE  51 

obtained  by  a  given  medical  inspector  in  Philadelphia 
after  the  addition  of  a  school  nurse  to  his  staff.  In 
each  case  the  height  of  the  first  column  shows  the 
percentage  of  recommendations  acted  upon  by  the 
parents  before  the  employment  of  the  nurse;  the 
second  column  after  her  employment. 

In  a  majority  of  cases  parental  neglect  spells  igno- 
rance. The  postal  card  notification  is  a  poor  educa- 
tional device.  The  nurse  goes  into  the  home  and  by 
tactful  presentation  of  the  child's  case  effects  what 
no  other  agency  could  accomplish.  She  not  only 
secures  action  in  the  case  at  hand,  but  she  becomes  a 
permanent  advisory  influence  in  the  homes  where 
she  visits.  She  does  what  the  iron  hand  of  law  could 
not  do.  We  can  hardly  imagine  any  kind  of  legal 
machinery,  devised  for  compelling  parental  treatment 
of  children's  defects,  which  would  succeed  in  as  large 
a  percentage  of  cases  as  does  the  school  nurse. 

School  nurses  reduce  absence 

In  the  second  place,  medical  inspection  without 
school  nurses  is  always  a  costly  tax  on  attendance. 
Children  with  scabies,  impetigo,  pediculosis,  etc.,  are 
sent  home  by  the  thousand,  to  mingle  on  the  street 
with  other  children  after  school  hours,  beyond  the 
control  of  the  school  and  without  effective  treatment. 
Where  diseases  of  this  kind  are  either  treated  by  the 
nurses  at  school  or  by  the  parents  after  her  instruc- 
tion, exclusions  are  usually  reduced  to  5  or  10  per 
cent  of  the  number  previously  necessary.    In  New 


52  HEALTH  WORK  IN  THE  SCHOOLS 

York  City  the  reduction  was  from  about  10,000  to 
about  1000  per  month.  In  a  quarter  of  a  school 
year  exclusions  were  enforced  in  New  York  as  fol- 
lows: — 

Measles 18 

Diphtheria. 140 

Scarlet  fever 13 

Whooping-cough 61 

Mumps 13 

Chickenpox 172 

Trachoma 1264} 

Pediculosis 3994  I    theJe  exclusions 

Skin  diseases 661  |    Preventable  by 

«.  I    school  nursing. 

Miscellaneous 1823J 

Over  95  per  cent  of  the  above  exclusions  would  have 
been  prevented  by  the  school  nurse.  By  her  ministra- 
tions and  instruction  in  the  home  these  diseases  of 
filth  and  neglect  are  almost  eliminated.  As  expressed 
by  Jane  Addams: x  — 

The  best  of  medical  inspection  succeeds  only  in  sending 
the  child  home;  they  say  that  such  and  such  a  child  would 
have  a  bad  effect  on  the  other  children,  and  therefore  he  is 
sent  back  to  the  family  physician  for  treatment.  In  most 
cases  a  family  physician  is  not  called  in,  because,  in  the  words 
of  Artemus  Ward,  "there  ain't  none";  and  therefore  the  child 
is  kept  out  indefinitely,  and  the  public  school,  so  far  as  that 
child  is  concerned,  is  doing  nothing,  and  the  child  continues 
to  play  in  the  alley  and  on  the  street  or  sit  in  the  doors  of  the 
tenement  with  the  rest  of  the  children.  This  is  the  whole 
idea  —  that  medical  inspection  was  succeeded  and  almost 
transposed  by  the  addition  of  the  visiting  nurses.  The  med- 
ical inspection  got  the  child  out  of  school,  and  the  visiting 
nurse  got  the  child  back.  It  seems  almost  foolish  to  have 
medical  inspection  without  the  visiting  nurse. 

1  Am.  J.  Nursing,  1908. 


THE  SCHOOL  NURSE  53 

Other  functions  of  the  school  nurse 

By  virtue  of  her  room  to  room  visitation  and  her 
opportunities  for  observation,  the  school  nurse  also 
becomes  the  ideal  sanitary  inspector.  She  notes  tem- 
peratures, ventilation,  seating,  cleanliness  of  room, 
toilets,  blackboards,  and  the  clothes  of  children.  Her 
hospital  standards  of  sanitation  tend  to  follow  her 
into  the  schools. 

In  special  schools  for  the  tuberculous,  crippled,  or 
anaemic  children,  the  school  nurse  is  indispensable. 
She  records  body  temperatures,  supervises  the  diet, 
the  sleep,  and  the  play  of  the  children,  and  advises 
continually  with  parents,  teachers,  and  doctors.  In 
some  such  schools  her  constant  presence  is  as  neces- 
sary as  in  the  hospital  ward. 

Again,  the  school  nurse  becomes  an  invaluable  as- 
sistant in  the  teaching  of  hygiene  to  pupils.  Every 
pupil  ought  to  have  more  expert  instruction  on  such 
subjects  as  home-nursing  and  first  aid  in  emergencies 
than  the  average  teacher  can  be  reasonably  expected 
to  give.  This  deserves  a  special  place  in  the  seventh 
and  eight  grades.  In  the  matter  of  sex  hygiene,  too, 
the  school  nurse  can  give  much  personal  advice  and 
instruction  to  the  older  girls.  As  has  been  pointed  out 
by  Miss  Stewart,1  the  nurse,  more  than  almost  any 
other  social  worker,  sees  the  dreadful  havoc  wrought 
by  ignorance  of  the  laws  of  sex.  She  becomes  vividly 

1  Ninth  Year-Booh  of  the  National  Society  for  the  Scientific  Study 
of  Education,  p.  5. 


54  HEALTH  WORK  IN  THE  SCHOOLS 

impressed  with  the  necessity  of  such  teaching  as  will 
supply  to  young  girls  the  power  and  motive  for  self- 
protection.  Girls  are  willing  to  consult  her  the  more 
readily  because  they  realize  that  this  is  an  everyday 
subject  with  her. 

Influence  of  school  nurses  upon  the  home 

The  school  nurse,  like  the  municipal  district  nurse, 
is  first  and  last  a  social  worker.  Important  as  are  her 
duties  in  the  school,  her  ministrations  and  educative 
influence  in  the  home  are  more  valuable  still.  She 
instructs  ignorant  but  fond  mothers  in  the  best 
methods  of  feeding,  clothing,  and  caring  for  their 
children.  She  is  received  in  their  homes  as  no  other 
official  visitor  could  possibly  be.  Mothers  are  quick 
to  detect  the  genuineness  of  her  interest  in  their  chil- 
dren, and  are  often  ready  to  follow  with  blind  faith 
any  instructions  she  has  to  offer.  At  her  advent  in  a 
tenement  or  street,  the  mothers  not  infrequently 
crowd  eagerly  around  her,  plying  her  with  questions 
and  bringing  their  babies  for  inspection.  The  school 
nurse  is  thus  a  potent  factor  in  diminishing  infant 
mortality.  In  short,  Dr.  Osier  does  not  overstate  the 
case  when  he  says  that  the  visiting  nurse  is  "a  minis- 
tering angel  everywhere. "  In  many  a  family  she  be- 
comes a  spiritual  adviser,  not  only  pointing  out  in- 
adequate sanitation  which  keeps  them  sick,  but  also 
educating  them  on  the  folly  of  cut-throat  chattel 
mortgages,  unnecessary  furniture  purchased  at  ruin- 
ous prices  on  the  installment  plan,  the  short-sighted 


THE  SCHOOL  NURSE  55 

policy  of  taking  children  prematurely  out  of  school 
to  work,  etc. 

All  of  this  is  especially  important  in  the  Ameri- 
canization of  the  more  ignorant  foreign-born  popu- 
lation. As  stated  by  Dr.  Darlington,  of  New  York 
City:  — 

In  all  large  communities,  the  poorer  element  of  the  foreign- 
born  population  presents  the  greatest  problem  encountered 
in  municipal  health  work.  Diversified  in  their  habits,  often 
superstitious  and  resentful  of  any  interference  with  their 
mode  of  life,  oppressed  by  poverty,  frequently  ignorant  or 
neglectful  of  the  simplest  sanitary  requirements,  their  assim- 
ilation as  citizens  of  their  adopted  country  comes  only  as 
result  of  education  —  persistent,  inclusive,  and  never-end- 
ing. In  public  health  work  this  education  is  brought  about 
by  various  means.  Lectures,  printed  instructions,  and  pub- 
licity in  all  its  forms  are  used,  but  the  most  valuable  and 
effective  form  is  found  in  individual  instruction  in  the  home. 
Personal  efforts,  advice,  instruction,  and  demonstration  offer 
the  most  practical  and  effective  means,  and  we  have  found 
the  employment  of  trained  nurses  for  this  purpose  of  ines- 
timable value. 

That  the  visiting  nurse  is  a  good  economic  invest- 
ment is  evidenced  by  the  fact  that  some  of  the  large 
insurance  companies,  such  as  the  Metropolitan  Life 
of  New  York  City,  find  it  to  their  advantage  to  em- 
ploy a  number  of  them  to  visit  the  homes  of  policy- 
holders for  the  purpose  of  giving  instruction  in  mat- 
ters of  hygiene.  Department  stores  and  factories  also 
find  it  good  business  to  employ  nurses  to  look  after 
the  health  of  their  employees  and  to  teach  them 
personal  hygiene.    The  visiting  nurse  is  a  "health 


56         HEALTH  WORK  IN  THE  SCHOOLS 

Number  needed 

The  number  of  school  nurses  needed  varies  some- 
what according  to  social  conditions,  and  according 
to  the  range  of  duties  expected  of  them.  We  find  all 
the  way  from  1,000  to  10,000  children  under  the  care 
of  one  nurse.  In  New  York  City  each  nurse  has  from 
two  to  seven  schools,  with  a  total  attendance  of  about 
4000  children.  In  Philadelphia  five  schools  and  about 
5000  children  are  usually  allotted  to  one  nurse,  while 
in  Boston  the  proportion  of  nurses  is  almost  twice  as 
great.  Nor  is  it  at  all  demonstrated  that  the  point  of 
diminishing  returns  has  yet  been  reached  in  the  num- 
ber employed.  It  is  not  improbable  that  the  ratio 
will  be  increased  until  it  reaches  an  average  of  one 
nurse  for  each  1000  of  the  school  enrollment.  If  there 
were  one  nurse  for  every  2000  pupils,  about  10,000 
would  be  required  in  the  entire  United  States.  A 
nurse's  room,  completely  equipped,  is  coming  to  be 
regarded  as  one  of  the  essentials  in  every  school  build- 
ing of  eight  or  more  rooms. 

Thus  far  the  institution  of  school  nursing  has  not 
spread  to  rural  communities  in  the  United  States, 
though  it  has  done  so  to  a  certain  extent  in  England. 
This  cannot  be  attributed  to  any  lack  of  need,  but 
only  to  the  greater  expense  and  other  obstacles  inci- 
dent to  a  more  scattered  population.  As  our  country 
districts  become  more  densely  populated,  and  as  they 
resort  more  often  to  school  consolidation,  the  nurse  will 
here,  also,  become  a  necessary  part  of  the  school  force. 


THE  SCHOOL  NURSE  57 

Equipment  needed  by  school  nurses 

With  such  an  extensive  scope  of  duties,  oppor- 
tunities, and  difficulties,  it  at  once  becomes  evident 
that  both  the  personal  qualities  and  the  professional 
training  of  the  school  nurse  are  matters  of  great  im- 
portance. She  must  be  quick  to  understand  every 
class  and  condition  of  people,  patient,  sympathetic, 
and  tactful.  All  agree  that  tact  is  absolutely  essential. 
She  must  be  simple,  direct,  concrete,  forceful,  con- 
vincing. Her  business  is  not  to  entertain,  but  to  get 
things  done,  and  she  must  therefore  be  persuasive 
as  well  as  pleasing. 

On  the  professional  side,  besides  having  a  good 
high-school  education  and  a  complete  course  in  a 
nurses'  training  school  of  recognized  standing,  she 
should  have  had  some  months  of  additional  experi- 
ence in  a  children's  hospital.  She  must  also  know 
something  of  education,  child  psychology,  general 
hygiene,  nutrition,  infant  mortality,  child-welfare 
movements,  domestic  sanitation,  and  certain  legal 
matters.  If  she  has  had  previous  experience  as  a  dis- 
trict nurse  or  as  a  teacher,  so  much  the  better.  Good 
health  and  willingness  to  work  are  of  course  taken  for 
granted. 

With  the  rapid  multiplication  of  school  nurses  the 
desirability  of  special  professional  training  for  them 
will  become  more  obvious.  Teachers  College,  Colum- 
bia, has  already  introduced  a  one-year  course  for  this 
purpose,  designed  to  follow  the  usual  two-year  train- 


58  HEALTH  WORK  IN  THE  SCHOOLS 

ing  for  nurses.  Courses  of  this  nature  will  no  doubt 
be  established  at  an  early  date  in  other  teachers' 
colleges,  and  perhaps  also  in  connection  with  medical 
schools.  The  school  nurse  has  proved  her  worth  to 
the  most  skeptical,  but  her  usefulness  can  be  greatly 
enhanced  by  the  requirement  of  a  professional  train- 
ing which  gives  special  attention  to  problems  of  school 
hygiene. 

A  Plan  For  the  Health  Supervision  of  Schools 

*by  Nurses  Alone  ! 

This  plan  is  adapted  to  places  which  are  unable, 
or  think  they  are  unable,  to  procure  expert  medical 
service  in  schools.  It  has  been  amply  demonstrated 
that  well-trained  nurses  are  able  to  accomplish  ex- 
tremely useful  results,  even  without  the  direct  aid 
of  medical  supervision.  The  plan  has  been  in  success- 
ful operation  in  Alameda,  California,  since  1911,  and 
is  soon  to  be  established  at  Ely,  Austin,  Cloquet, 
Owatonna,  and  a  number  of  other  towns  of  Min- 
nesota. 

Properly  trained  nurses  are  able  to  detect  most  of 
the  physical  handicaps  of  school  children.  Such  nurses 
have  no  difficulty  in  discovering  common  defects  of 
the  nervous  sytem,  eyes,  ears,  throat,  teeth,  skin, 
and  lymph  glands  of  the  neck.  They  can  usually 
detect  the  presence  of  adenoids  and  note  disorders  of 
nutrition,  as  well  as  observe  defective  postures.  About 

1  This  is  the  second  plan  for  school  health  supervision,  mentioned 
on  page  42,  chapter  in. 


THE  SCHOOL  NURSE  59 

the  only  points  of  importance  which  they  ought  not 
to  attempt  to  cover  in  their  examinations  are  those 
which  pertain  to  certain  special  conditions  requiring 
exact  diagnosis.  These  would  include  the  heart,  lungs, 
special  diseases  of  the  skin  and  nervous  system,  and 
some  of  the  unusual  contagious  diseases  of  childhood. 
Certainly  more  than  90  per  cent  of  the  usual  defects 
of  school  children  will  be  observed  by  the  rightly 
trained  school  nurse,  and  this  plan  will  inevitably 
justify  itself  and  gradually  lead  to  more  thorough 
organization  with  medical  service. 

According  to  Dr.  R.  C.  Cabot,  of  the  Harvard 
Medical  School,  the  school  nurse  comes  to  excel  the 
young  doctor  in  detecting  the  first  symptoms  of  in- 
fectious disease.  The  results  of  nurse  inspection  in 
Boston  prove  her  efficiency  in  this  line.  Under  the 
inspection  of  doctors  and  teachers  the  average  number 
of  cases  of  scarlet  fever  discovered  annually  in  the 
schools  was  14.  In  1908,  the  school  nurses  found  1000 
cases.  Where  the  doctors  and  teachers  had  found  an 
annual  average  of  86  cases  of  measles,  the  school 
nurses  discovered  2285!  This  disparity  in  efficiency, 
however,  is  in  reality  a  disparity  between  nurses  and 
teachers,  as  previous  to  the  introduction  of  nurses 
the  physicians  had  examined,  for  the  most  part,  only 
those  children  sent  to  them  by  the  teachers  as  suspects. 

The  following  communication  is  from  Louis  W. 
Rapeer,  who  has  made  an  exceptionally  thorough 
study  of  the  results  of  medical  inspection  in  about 
forty  American  cities :  — 


60  HEALTH  WORK  IN  THE  SCHOOLS 

I  have  come  to  the  tentative  conclusion  that  many 
schools  do  not  need  physicians,  and  that  a  great  deal  would 
be  gained,  and  little  or  nothing  lost,  by  employing  experi- 
enced school  nurses  for  each  group  of  1000  to  1800  pupils. 
New  York  City,  as  well  as  other  cities,  has  proved  that 
school  nurses  can  inspect  for  contagious  diseases.  Canton, 
Massachusetts,  also  has  shown  that  only  the  nurse  is 
needed.1 

Physicians  for  less  than  one  hour  a  day  cost  about  half 
what  nurses  cost  for  full  time,  five  and  a  half  days  a  week.  A 
school  nurse  when  trained,  one  who  has  the  study  habit,  can 
also  make  the  physical  examinations  and  record  the  findings 
on  a  history  card  for  each  pupil,  especially  for  defects  of  ears, 
eyes,  nose,  mouth,  throat,  skin,  scalp,  malnutrition,  and  ner- 
vousness,— about  97  per  cent  of  all.  Nurses  very  much  les- 
sen professional  jealousy  among  the  doctors;  get  far  better 
response  from  children  and  from  parents;  get  cures,  the  great 
object  of  medical  supervision;  open  the  eyes  of  teachers 
to  the  symptoms  of  ailments  and  defects ;  follow  up  better  the 
children  they  themselves  examine;  cooperate  better  with 
women's  clubs,  dentists,  dispensaries,  and  oculists;  get  back 
the  truants  and  absentees;  keep  doWn  impetigo,  lice,  and 
infant  mortality  in  the  summer;  distribute  literature  on  the 
cure  and  prevention  in  the  homes;  and  in  general  are  on  the 
job  all  the  time  as  a  life-work,  not  as  a  perfunctory  side 
issue.  Three  hours  each  morning  for  inspection  and  20  exam- 
inations; afternoons  for  inspection  and  home  visiting  — 
about  1000  to  1800  children. 

Occasionally  physicians  object  to  allowing  school 
nurses  to  make  health  examinations  or  to  treat  cuts, 
bruises,  sores,  and  the  like.  The  tendency,  however, 
is  to  the  extension  rather  than  the  restriction  of  their 
duties.  There  is  no  reason  why  physicians  should 
view  this  with  apprehension  since  the  nurse's  work 

1  See  Dr.  Arthur  Cabot's  article  in  The  Physicians  and  Surgeon  s 
Journal  for  May,  1911,  and  the  September,  1911,  report  of  the  Bu- 
reau of  Municipal  Research,  261  Broadway,  New  York. 


THE  SCHOOL  NURSE  61 

finds  its  natural  limitations  without  any  need  for  arti- 
ficial restriction. 

In  every  instance  where  nurses  are  employed  to 
make  the  examinations  of  pupils,  one  or  more  physi- 
cians ought  to  be  available  for  special  consultation 
in  questionable  and  unusually  important  cases. 

The  hearty  cooperation  of  teachers  will  also  be 
required  in  this  scheme  and  they  ought  to  make  use 
of  an  outline  of  health  grading,  such  as  that  presented 
in  chapter  v. 

SELECTED    REFERENCES 

(Only  the  most  important  references  are  given  here.  A  complete  bibliography  will 
be  found  in  the  Ninth  Y ear-Book  of  the  National  Society /or  the  Study  0/  Education, 
referred  to  below.) 

1.  Allport,  Dr.  Frank:  The  School  Nurse. 
*2.  Cornell,  W.  S. :  Health  and  Medical  Inspection  of  School  Chil- 
dren.  1912,  pp.  76-89. 

8.  Crowley,  Ralph  H.:  The  Hygiene  of  School  Life.  1910,  pp.  181- 
83. 

4.  Forbes,  Duncan:  "The  School  Nurse."  See  Kelynack's  Medi- 
cal Inspection  of  Schools.   1910,  chapter  xvn,  pp.  264,  274. 
*5.  Gulick  and  Ayres:  Medical  Inspection  of  Schools.   (Chapter  v. 

"The  School  Nurse,"  pp.  62-71.) 
*6.  Hogarth,  A.  H. :  Medical  Inspection  of  Schools.    1909,  chapter 
xii.  pp.  172-86. 
7.  Leipoldt,  C.  L.:  The  School  Nurse.  London,  1912. 
*8.  Newmayer,  Dr.  S.  W.:  "Evidences  that  the  School  Nurse 
Pays."   Proc.  of  Fifth  American  Cong.  School  Hygiene,  1911. 
pp.  44-51. 

9.  Nutting,  Adelaide:  "The  Nurse  in  the  Public  School."  Rept. 
of  U.S.  Bureau  of  Education,  No.  1906,  chapter  vni. 

*10.  "The  Nurse  in  Education,"  being  the  Ninth  Year  Book  of  the 
National  Society  for  the  Study  of  Education.   1911,  pp.  72. 
11.  Poelchau,  Dr.  G.:    "Bericht  iiber   die  Tatigkeit  der  Schul- 
schwestern  in  Charlottenburg  in  Schuljahre  1909-10."   Inter. 
Mag.  Schulhyg.,  1911,  pp.  263-79. 


r 


CHAPTER  V 

THE  HEALTH  GRADING  OF  SCHOOL  CHILDREN 
BY  TEACHERS1 

•   The  General  Importance  of  the  Teacher's 
Cooperation 

The  cooperation  of  the  teacher 

The  effectiveness  of  any  system  of  health  super- 
vision in  the  schools  depends  in  large  measure  upon 
securing  the  intelligent  and  willing  cooperation  of  the 
teachers.  The  more  prominent  the  preventive  aspect 
of  the  work  done,  the  more  important  this  becomes. 
A  large  part  of  the  doctor's  advice  has  to  be  acted 
upon  finally,  if  at  all,  by  the  teacher.  She  is  the  only 
person  in  constant  attendance  upon  the  pupils.  She 
has  even  larger  opportunity  than  the  school  nurse  to 
detect  the  first  symptom  of  contagious  disease  in  the 
school.  It  would  be  well  if  normal  schools  afforded 
to  young  teachers  a  more  satisfactory  training  in 
school  hygiene.  They  would  then  be  able  to  cooperate 
more  intelligently  in  the  management  of  all  kinds  of 
atypical  children,  —  the  precocious,  the  mentally  de- 
fective, the  incorrigible,  the  physically  defective,  the 
timid,  the  quarrelsome,  the  stuttering,  the  neuras- 
thenic, etc. 

1  This  is  the  third  plan  for  the  health  supervision  of  schools  men- 
tioned on  page  42,  chapter  in. 


HEALTH  GRADING  63 

The  teacher's  part  in  molding  the  health  habits  of 
pupils  is  equaled  by  that  of  no  other  agency.  It  de- 
volves upon  the  teacher  to  cultivate  habits  of  posture 
which  will  prevent  spinal  curvature  and  myopia,  and 
habits  of  physical  activity  which  will  help  to  counter- 
balance the  effects  of  sedentary  life  and  ward  off 
disease.  It  is  her  duty  to  impart  the  knowledge  of 
hygiene  and  ideals  of  correct  living  which  will  func- 
tion throughout  life  as  the  cheapest  form  of  health 
insurance  and  the  most  effective  protection  against 
immorality  and  vice.  The  responsibility  of  the  school 
for  the  child's  health  does  not  cease  with  the  close  of 
school  life. 

Besides  assisting  the  physician,  with  records  and 
other  routine  work,  teachers  are  also  frequently 
charged  with  the  testing  of  vision  and  hearing.  This 
practice  has  become  especially  common  in  the  United 
States.  At  present  legal  enactments  in  many  States, 
including  Colorado,  Connecticut,  Indiana,  Maine, 
Massachusetts,  Minnesota,  and  Utah,  provide  that 
sight  and  hearing  tests  be  made  by  the  teacher,  and 
such  tests  are  the  custom  in  probably  a  majority  of 
American  cities.  To  a  less  extent  this  has  been  done 
also  in  England  and  Scotland. 

Teachers  vs.  physicians 

Physicians  sometimes  oppose  this  extension  of  the 
teacher's  work  into  a  field  which  they  regard  as  one 
that  should  be  reserved  for  a  higher  degree  of  ex- 
pertness  than  the  average  teacher  can  be  expected  to 


64  HEALTH  WORK  IN  THE  SCHOOLS 

possess.  Some  of  the  best  oculists  and  aurists  in  the 
country,  however,  have  taken  the  other  view.  In- 
deed, it  has  been  largely  due  to  the  influence  of  such 
specialists  themselves  that  these  routine  examina- 
tions have  been  so  generally  entrusted  to  teachers  and 
nurses.  In  1906,  when  the  legislature  of  Massachu- 
setts was  considering  a  mandatory  provision  by  which 
vision  and  hearing  were  to  be  tested  by  teachers, 
sittings  were  held  during  which  a  mass  of  evidence  as 
to  the  feasibility  of  the  plan  was  offered  by  some  of 
the  best-known  specialists  of  the  State.  Tests  of  the 
kind  here  referred  to  can  be  made  by  any  one  who  is 
competent  to  teach.  It  is  not  claimed  that  the  teacher 
can  assume  the  expert  functions  of  the  oculist  or 
aurist,  and  the  making  of  sight  and  hearing  tests  does 
not  require  that  they  should  do  so.  It  is  claimed,  and 
is  now  fairly  well  recognized,  that  they  are  at  least 
as  capable  of  making  tests  of  the  special  senses  as  is 
the  physician  who  is  not  also  a  specialist.  It  should 
be  stated,  however,  that,  wherever  this  policy  is  fol- 
lowed, the  intention  is  to  have  examinations  made  by 
specialists  in  all  cases  where  defects  are  apparently 
revealed  by  the  teacher's  test. 

Teachers  should  have  special  instruction  and  prac- 
tice to  aid  them  in  reading  the  health  index  of  the 
child  for  all  the  common  diseases  and  defects. 

The  contribution  that  can  rightfully  be  expected 
from  teachers  in  all  these  lines  depends  in  part  upon 
the  size  and  efficiency  of  the  school  nursing  corps. 
In  general,  the  more  nurses  the  less  it  will  be  neces- 


HEALTH  GRADING  65 

sary  to  require  of  the  teachers.  This  applies  especi- 
ally to  the  detection  of  contagious  diseases  and  physi- 
cal defectiveness,  first-aid  work,  follow-up  service, 
etc.  But  the  responsibility  of  conducting  the  activi- 
ties of  the  school  in  such  a  way  as  to  transgress  as 
little  as  possible  the  fundamental  laws  of  hygiene  is 
one  which  the  teacher  can  never  wholly  shift.  Any 
scheme  of  medical  inspection  or  health  supervision 
which  does  not  succeed  in  enlisting  the  interests  and 
enthusiastic  support  of  the  teachers  fails  in  one  of  the 
most  fundamental  requirements. 

An  Outline  for  the  Health  Grading  of  School 
Children  by  Teachers 

Health  supervision  of  schools,  must  in  many  places, 
at  present,  be  delegated  largely  or  entirely  to  teachers, 
a  fact  which  we  cannot  ignore.  For  this  special  work, 
however,  very  few  teachers,  or  even  nurses,  have 
received  adequate  training. 

In  order  to  help  meet  this  condition  as  it  exists  in 
the  schools,  the  following  Outline  for  a  Health  Survey 
of  School  Children  is  suggested.  Its  use  will  succeed 
not  only  in  largely  removing  the  usual  obstacles  to 
health  supervision  in  a  community,  but  even  where 
such  obstacles  do  not  exist,  the  plan  when  put 
into  operation  will,  it  is  believed,  greatly  assist 
those  engaged  in  the  health  care  of  children  in  the 
schools. 

The  plan  consists  of  two  parts :  — 

I.  An  outline  for  a  partial  health  survey  to  be  made 


66         HEALTH  WORK  IN  THE  SCHOOLS 

by  the  aid  of  the  pupils  themselves,  or,  in  the  case  of 
young  children,  by  the  aid  of  parents. 

II.  An  outline  for  a  more  extensive  health  survey 
on  the  part  of  teachers  (or  nurses).  Whether  a  medical 
officer  and  nurse  are  employed,  or  not,  does  not  much 
affect  the  plan;  although,  of  course,  any  scheme  for 
health  supervision  in  schools  will  succeed  best  where 
competent,  specially  trained  professional  service  is 
available. 

The  answers  to  these  questions  on  the  part  of  pupils 
or  their  parents  will  furnish  some  very  definite  in- 
formation in  respect  to  physical  and  mental  condi- 
tions, and  prove  valuable  to  every  teacher.  The 
answers  under  Part  II  will  stimulate  and  encourage 
observation  on  the  part  of  the  teacher  and  will  also 
supply  a  very  considerable  amount  of  useful  informa- 
tion which  may  serve  as  a  basis  for  practical  hygiene 
teaching.  With  the  employment  of  this  survey,  no 
school  need  wait  for  the  appointment  of  a  medical 
officer  before  beginning  some  effective  health  work 
with  school  children. 

In  making  the  survey  the  teacher  may  take  her  own 
time.  If  it  is  completed  in  a  room  of  twenty  to  forty 
pupils  in  a  month  or  six  weeks,  it  will  be  quite  satis- 
factory. Any  teacher  will  be  able  to  accomplish  it 
without  feeling  that  she  is  imposed  upon.  After  a 
pupil's  health  survey  is  made,  a  notice  should  be  sent 
to  the  parents  in  those  cases  where  physical  difficulties 
appear  to  exist.  This  notice  may  be  very  general  and 
noncommittal  in  character,   and  should  always  be 


HEALTH  GRADING  67 

signed  by  the  principal  of  the  school.  Such  a  notice 

has    been    successfully    employed    in  the   following 
form:  — 


To  the  Parent  of 

The  teacher  of  this  child  has  reason  to  believe  that 
he  is  suffering  from  physical  defects,  serious  enough 
to  need  attention.  An  examination  by  your  family 
physician  or  dentist  is,  therefore,  advised. 

For  further  details  you  are  invited  to  call  at  the 
office  of  the  Principal  at  any  time  you  may  find  it 
convenient. 

Very  sincerely  yours, 
Principal  of  School. 

A  health  survey  carried  out  in  the  manner  suggested 
will  result:  — 

(1)  In  overcoming  most  of  the  prejudice  against 
physical  examinations  of  school  children. 

(2)  In  educating  the  public  in  matters  of  child 
hygiene  and  preventive  medicine. 

(3)  In  largely  solving  the  question  of  expense. 

(4)  In  the  discovery  of  probably  90  per  cent  of  the 
urgent  cases  of  physical  defects. 

(5)  In  considerably  decreasing  the  wear  and  tear 
on  the  teacher. 

(6)  In  considerably  increasing  the  children's  health, 
happiness,  and  efficiency. 

(7)  In  serving  as  a  useful  preliminary  examination 
for  a  medical  officer  of  schools  so  that  he  may  know 
where  to  concentrate  his  attention. 

(8)  In  giving  positive  information  in  respect  to 
the  kind  of  hygiene  teaching  which  is  most  needed. 

The  significance  of  all  the  answers  obtained  by  the 


68         HEALTH  WORK  IN  THE  SCHOOLS 

use  of  the  questions  in  the  health  survey  may  not 
at  first  be  appreciated  by  the  teacher  or  other  person 
without  medical  training,  but  experience  and  a  little 
study  will  gradually  make  this  matter  plain. 

Part  I  of  Health  Survey 

Questions  to  be  answered  by  pupil  or  parent,  or  by  pupil  with 
aid  of  the  teacher 

Name School Date 

Question    1:  How  old  are  you? 

Answer: 

Question    2:  What  grade  are  you  in? 

Answer : 

Question  3:  Have  you  ever  had  any  serious  sickness?  What 
was  it? 

Answer : 

Question    4:  What  do  you  usually  eat  for  breakfast? 

Answer: 

Question    5:  Do  you  eat  breakfast  every  day? 

Answer : 

Question    6:  Do  you  eat  a  noon  meal  every  day? 

Answer: 

Question    7:  Do  you  drink  coffee?  How  much? 

Answer : 

Question    8:  Do  you  drink  tea?  How  much? 

Answer: 

Question  9 :  Do  you  have  your  bedroom  window  open  or 
shut  at  night? 

Answer: 

Question  10:  Have  you  ever  been  to  a  dentist? 

Answer : 

Question  11:  Do  you  own  a  toothbrush? 

Answer: 

Question  12:  Do  you  use  a  toothbrush? 

Answer : 

Question  13:  Do  you  sometimes  have  toothache? 

Answer: 


HEALTH  GRADING  69 

Question  14:  Do  you  have  headache  often? 

Answer : 

Question  15 :  Can  you  read  easily  what  is  written  on  the 
blackboard? 

Answer: 

Question  16:  Does  the  print  blur  in  your  book? 

Answer: 

Question  17:  Do  you  often  see  double? 

Answer: 

Question  18:  Do  you  ever  have  earache? 

Answer: 

Question  19:  Do  your  ears  ever  run? 

Answer: 

Question  20:  Can  you  hear  easily  what  the  teacher  says? 

Answer : 

Question  21 :  Is  it  hard  for  you  to  breathe  through  your  nose? 

Answer: 

Question  22:  Do  you  have  sore  throat  often? 

Answer: 

Question  23:  Do  you  tire  easily  in  school? 

Answer: 

Question  24:  Do  you  work  any  out  of  school  hours? 

Answer : 

Question  25:  What  kind  of  work? 

Answer: 

Question  26:  How  much? 

Answer: 

Additional  optional  questions 

Question  27:  What  time  do  you  go  to  bed? 

Answer: 

Question  28:  What  time  do  you  get  up? 

Answer: 

Question  29:  Does  any  one  else  use  your  toothbrush? 

Answer: 

Question  30:  Do  you  eat  candy  every  day? 

Answer: 

Question  31:  How  often  do  you  bathe? 

Answer : 

Question  32:  Do  you  often  take  cold? 

Answer : 


70  HEALTH  WORK  IN  THE  SCHOOLS 

Part  II  of  Health  Survey 
Questions  to  be  answered  by  the  teacher  or  nurse 


A.   General  appearance 

1.  Is  the  child  healthy  appearing? 

2.  Is  his  color  good? 

3.  Is  he  physically  well  developed? 

4.  Is  he  free  from  apparent  deformities? 

5.  Has  he  a  good  standing  posture? 

6.  Has  he  a  good  sitting  posture? 

7.  Are  the  shoulders  even? 

8.  Does  the  child  walk  normally? 

9.  Are  the  two  sides  of  the  shoe  heels  worn 
evenly? 

10.  Is  the  physiological  age  of  the  child  appar- 
ently equal  to  his  chronological  age? 

B.  Mental  conditions 

1.  Is  the  child  normally  advanced  in  school?.  . 

2.  Is  he  mentally  alert? 

3.  Does  he  answer  ordinary  questions  intelli- 
gently?  

4.  Does  he  play  normally? 

C.  Nervous  conditions 

1.  Is  the  child  good-tempered? 

2.  Is  he  free  from  abnormal  emotion? 

3.  Does  he  have  good  powers  of  muscular  coor- 
dination?  

4.  Is  he  free  from  spasmodic  movements? 

5.  Is  he  free  from  the  nail-biting  habit? 

6.  Does  he  speak  without  stammering? 

7.  Is  he  free  from^QM|ifbunced  peculiarities  such 
as  irritability,  timidity,  embarrassment, 
cruelty,  moroseness,  fits,  general  misbe- 
havior, etc.? 

8.  Is  he  apparently  free  from  bad  sexual  habits? 


Yes 


No 


HEALTH  GRADING 


71 


9.  Is  he  free  from  so-called  "bladder  trouble" 

(requests  to  "go  out")? 

10.  Is  he  usually  free  from  headache? 

D.    Teeth 

1.  Are  the  teeth  clean? 

2.  Are  the  teeth  sound? 

3.  Are  the  six-year  molars  in  good  condition? 

4.  Has  the  child  been  to  a  dentist  within  six 
months? 

5.  Are  the  teeth  regular? 

6.  Does  the  child  use  a  toothbrush  every  day?. 

7.  Are  the  gums  free  from  abscesses? 

8.  Are  the  gums  healthy-looking? 

9.  Are  the  upper  teeth  straight  (not  prominent)  ? 
10.  Have  decayed  teeth  been  filled? 

E.  Nose  and  throat 

1 .  Does  the  child  breathe  with  the  mouth  closed  ? 

2.  Is  he  free  from  chronic  nasal  discharge? 

3.  Is  he  free  from  "nasal  voice  "? 

4.  Has  he  a  well-developed  face? 

5.  Has  he  a  well-developed  chin? 

6.  Has  he  straight,  even  teeth? 

7.  Is  the  child  mentally  alert? 

8.  Is  he  usually  free  from  sore  throat? 

9.  Is  the  hard  palate  wide  (not  high  and  narrow)  ? 

10.  Is  the  hearing  good? 

11.  Does  the  child  breathe  quietly? 

F.   Ears 

1.  Does  the  child  usually  answer    questions 
without  first  saying  "what"? 

2.  Is  he  fairly  attentive? 

3.  Is  he  fairly  bright  appearing? 

4.  Does  he  have  a  voice  which  is  not  monoto- 
nous and  not  "expressionless"? 

5.  Does  he  spell  fairly  well? 


Yes 


No 


72 


HEALTH  WORK  IN  THE  SCHOOLS 


6.  Does  he  read  fairly  well? 

7.  Is  he  free  from  earache? 

8.  Does  he  hear  a  watch  tick  as  far  as  the  aver- 
age child? 

9.  Is  he  free  from  ear  discharge? 

10.  Is  he  free  from  any  peculiar  postures  which 

might  indicate  deafness? 

G.  Eyes 

1.  Are  the  child's  eyes  straight? 

2.  Is  he  free  from  chronic  headache? 

3.  Does  he  do  his  work  without  fatigue? 

4.  Is  he  free  from  squinting  or  frowning? 

5.  Is  the  child  free  from  postures  which  might 
indicate  eye  defects,  such  as  leaning  over  too 
near  the  desk,  holding  the  head  on  one  side, 
etc.? 

6.  Are  the  eyes  free  from  corneal  ulcers  or  scars? 

7.  Are  the  eyes  free  from  redness  and  discharge? 

8.  Are  the  eyelids  healthy-looking? 

9.  Can  the  child  read  writing  on  the  board  from 
his  seat? 

10.  Have  the  eyes  been  tested  separately  with 
the  Snellen  Test  Type? 

H.   Communicable  diseases  of  the  skin 

1.  Is  the  head  free  from  any  signs  of  disease 
(lice,  ringworm)  ? 

2.  Is  the  skin  of  the  face,  hands,  wrists,  fore- 
arms, and  chest  free  from  red,  somewhat  cir- 
cular patches  (ringworm)? 

3.  Is  the  skin  of  the  face,  hands,  and  forearms 
free  from  infected  spots  with  crusts  and  pus 
(impetigo)  ? 

4.  Is  the  child  free  from  red,  scratched  lines  and 
spots  on  the  hands,  wrists,  forearms,  chest, 
and  between  the  fingers  (itch)? 


HEALTH  GRADING 


73 


/.   Eruptive  children's  diseases 

The  following  points  often  indicate  the  early  signs  of  trans- 
missible diseases  in  children.  They  will  not  ordinarily  be 
observed,  of  course,  at  the  time  of  making  this  health  sur- 
vey:— 


1.  Flushed  face 

2.  Lassitude 

3.  Vomiting 

4.  Eruptions 

5.  Congested  eyes 

6.  Discharging  eyes . . . 

7.  Nasal  discharge 

8.  Persistent  coughing 

9.  Scratching 

10.  Aches  and  pains.. . . 

11.  Sore  throat 

12.  Headache 


Yes    No 


74         HEALTH  WORK  IN  THE  SCHOOLS 
BLANK  FOR  SUMMARY 

Physical  Development 

Nervous  System 

Nutrition 

Mental  Condition 

Eyes 

Ears 

Nose 

Throat 

Teeth 

Skin 

Eruptive  Disease 

Food 

Ventilation  of  Bedroom 

Coffee  Habits 

Tea  Habits 

Home  Habits 


HEALTH  GRADING 


75 


ABBREVIATED  CARD  FORM  OF  A  TEACHER'S 
HEALTH  SURVEY  OF  THE  SCHOOL  CHILD 

Name School 

Grade Age 

Date 


Yes 


No 


10. 
11. 

12. 
13. 
14. 

15. 

16. 

17. 

18. 
19. 

20. 
21. 
22. 
23. 
24. 
25. 


Have  you  ever  been  in  a  grade  more  than 

one  year? - 

Have  you  ever  had  any  serious  sickness?. 

Do  you  feel  strong  and  well  now? 

Do  you  eat  breakfast  every  day? 

Do  you  eat  a  noon  meal  every  day? 

Do  you  drink  coffee? 

Do  you  always  have  your  bedroom  win- 
dow open  at  night? 

Have  you  been  to  a  dentist  within  a  year? 

Do  you  have  toothache  often? 

Do  you  own  a  toothbrush? 

Do  you  use  your  toothbrush  every  day?. . 
Do  you  have  a  toothbrush  of  your  own?  . 
Do  you  have  much  trouble  with  headache? 
Can  you  read  writing  on  the  blackboard 

from  your  seat? 

Does  the  print  in  your  books  run  together 

or  look  dim  or  crooked? 

Do  your  eyes  hurt  after  reading  a  good 

while? 

Do  you  sometimes  see  two  letters  or  two 

lines  instead  of  one? 

Do  you  often  have  earache? 

Do  your  ears  ever  run? 

Can  you  always  hear  the  teacher? 

Do  you  go  to  bed  by  nine  o'clock? 

Do  you  go  to  bed  by  ten  o'clock? 

Do  you  bathe  at  least  once  every  week?. . 

Have  you  ever  been  vaccinated? 

Have  you  ever  had  smallpox? 


76          HEALTH  WORK  IN  THE  SCHOOLS 
Remarks :  — 


This  child  has  had  the  following  diseases  at  the  age  indicated  below: 


Chickenpox     when 

years  old 

Whoop  ing-co  ugh     when . . 

.  .years  old 

Diphtheria         "      

Pneumonia                  "     . . 

•<          M 

..       « 

Tonsillitis           "      

Smallpox                    "     . . 

m       .« 

<<       <• 

Infantile  paralysis     "     . . 

<t       <• 

*t 


HEALTH  GRADING  77 

Suggestions  for  Using  the  Outline  for  Health 
Grading 

1.  Call  the  pupils,  one  at  a  time,  to  the  desk.  Begin 
with  Part  I,  and  ask  the  questions  as  they  appear 
in  the  Outline  and  write  the  answers  yourself.  One 
can  get  a  great  deal  of  information  by  noticing  the 
manner  in  which  the  pupil  answers  the  question. 
Mistakes  in  answers  may  often  be  corrected  in  this 
way,  when  they  would  not  be  observed  if  the  pupil 
were  to  answer  the  questions  himself  in  his  own  writ- 
ing at  his  seat.  Do  not  suggest  the  answer. 

2.  In  asking  questions  about  headache  and  ear- 
ache, or  any  other  questions  where  the  word  "fre- 
quent" appears,  use  the  word  "  frequent "  as  meaning 
once  a  week  or  oftener. 

3.  Be  perfectly  sure  that  the  pupil  understands  the 
question,  and  test  his  answer  in  a  number  of  different 
ways  where  you  have  any  reason  to  doubt  the  reply 
given. 

4.  It  is  desirable  to  have  the  Outline  for  Health 
Grading  completed  for  every  pupil  in  your  room  be- 
fore the  arrival  of  the  visiting  physician. 

5.  After  the  completion  of  the  health  grading  in 
your  room,  make  a  list  of  the  pupils  who  you  think 
ought  to  receive  further  examination  by  a  phy- 
sician or  nurse.  Where  only  the  minor  difficulties 
are  discovered  it  is  not  necessary  to  call  the  atten- 
tion of  a  physician  to  these  points,  although  it  may 
sometimes  be  necessary,  by  means  of  the  blank  no- 


78  HEALTH  WORK  IN  THE  SCHOOLS 

tice,  to  inform  the  parents  of  what  you  discover.  Do 
not  place  any  pupils  on  the  list  to  be  examined  by  a 
physician  unless  you  have  a  definite  reason  for  doing 
so. 

6.  Make  a  list  of  all  the  retarded  pupils  in  your 
room,  and  of  this  number  indicate  those  whom  you 
suspect  of  being  mentally  deficient. 

The  Significance  of  the  Answers  to  the 
Questions  of  Part  I  of  the  Outline 

The  answers  in  Part  I  will  furnish  information  on 
the  following  points:  — 

1.  Retardation. 

2.  Influence  of  previous  sickness  on  present  condition. 

3.  Relation  of  home  habits  to  individual  health. 

4.  Condition  of  the  teeth. 

5.  Condition  of  the  eyes. 

6.  Condition  of  the  ears. 

7.  Condition  of  the  nose. 

8.  Condition  of  the  throat. 

9.  Amount  of  work  done  out  of  school. 
10.  Food  habits. 

Defective  teeth 

If  a  child  in  the  third  grade  or  above  has  never  been 
to  a  dentist,  it  is  presumptive  evidence  in  most  cases 
that  his  teeth  are  defective.  Testimony  of  aching 
teeth  always  indicates  defective  teeth;  sound  teeth 
never  ache. 

In  nearly  every  room  it  will  be  noted  that  several 
pupils  make  use  of  a  family  toothbrush.  Nothing  could 
more  effectually  spread  disease  than  this  practice. 


« 


I 


3 


^        ^*       !« 


1     9 


80         HEALTH  WORK  IN  THE  SCHOOLS 

Practically  every  school  disease  that  we  know  about 
is  spread  by  the  secretions  of  the  nose  and  throat. 
This  clearly  indicates  the  danger  from  the  use  of  the 
common  toothbrush. 

Chronic  headache 

Chronic  headache  in  school  children  is  usually 
caused  by  one  of  the  following  conditions:  — 

1.  Eye-strain. 

2.  Indigestion. 

3.  Constipation. 

4.  Auto-intoxication,  or  absorption  of  the  products  of 
fermentation  from  the  intestines. 

5.  Decayed  teeth. 

6.  Bad  ventilation  at  home,  or  at  school,  or  both. 

7.  Malnutrition. 

8.  Adenoids. 

While  there  are  some  other  causes  of  headache,  they 
are  so  infrequent  as  to  be  negligible  here.  Of  the  above 
causes  given,  eye-strain,  constipation,  and  auto-intoxi- 
cation are  probably  the  most  common. 

Eye-strain 

Blurring  of  the  print  always  indicates  some  form 
of  visual  defect  and  is,  therefore,  positive  evidence  of 
eye-strain.  It  is  always  well  to  ask  if  the  pupil  habit- 
ually sees  double;  also  if  he  notices  spots  before  the 
eyes,  if  the  letters  appear  to  move,  etc. 

Earache 

Chronic  earache  always  indicates  more  or  less  seri- 
ous trouble.    It  means  that  inflammation  is  present 


W 


HEALTH  GRADING  81 

in  the  ear.  In  many  cases  earache  is  due  to  the  pres- 
ence of  adenoids,  and  frequent  earache  always  indi- 
cates either  adenoids  or  some  other  abnormal  con- 
dition of  the  throat.  If  not  corrected,  earache  very 
frequently  leads  to  more  or  less  permanent  deafness. 

Discharging  ears 

This  condition  is  more  serious  than  earache,  and 
indicates  that  the  disease  process  in  the  ears  is  ad- 
vancing rapidly.  The  condition  should  always  be 
treated  at  the  earliest  possible  time.  Always  test  the 
hearing  of  pupils  who  have  earache  or  ear  discharge 
by  means  of  the  watch  tick  or  whispered  words.  As 
a  check  in  this  test  always  test  children  with  normal 
hearing  at  the  same  time.    Test  each  ear  separately. 

Difficult  nasal  breathing 

Children  who  complain  of  constant  difficulty  in 
breathing  through  the  nose  usually  have  adenoids. 
Sometimes  the  obstruction  is  in  the  nose  itself  and  in 
this  case  is  due  to  enlarged  turbinates  or  to  polypi. 
Many  children  with  adenoids  will  say  they  can  breathe 
easily  through  their  noses  simply  because  they  have 
never  breathed  normally,  and  do  not,  therefore,  know 
what  nasal  breathing  means.  Inquire  if  the  child's 
mouth  is  usually  dry  when  he  wakes  in  the  morning. 

Frequent  sore  throat 

This  condition  nearly  always  indicates  diseased 
tonsils,  and  should  always  receive  prompt  attention. 


82  HEALTH  WORK  IN  THE  SCHOOLS 

If  the  tonsils  are  much  enlarged,  adenoids  will  nearly 
always  be  found  present.  On  the  other  hand,  adenoids 
are  often  found  present  when  there  is  no  enlargement 
of  the  tonsils.  Rheumatism  is  often  associated  with 
diseased  tonsils.  So-called  "growing-pains,'*  stiff- 
neck,  and  tender,  aching  joints  are  common  symptoms 
of  rheumatism. 


The  Significance  of  Answers  to  Part  II 

General  appearance 

There  are  many  reasons  for  poor  general  appearance. 
The  most  common  is  probably  general  malnutrition, 
due  commonly  to  insufficient  food,  the  wrong  variety 
of  food,  or  the  wrong  use  of  food.  Some  other  causes 
are  the  following:  — 

Adenoids. 

Diseased  tonsils. 

Bad  ventilation. 

Very  rapid  growth. 

Tuberculosis. 

A  recent  sickness  of  some  kind. 

Very  defective  teeth. 

Peculiarities  in  posture,  walk,  etc. 
These  conditions  may  be  explained  in  general  by 
weak  muscles,  due  to  rapid  growth;  spinal  disease 
(often  tubercular);  flat-foot  or  weakened  arches;  rick- 
ets; tuberculosis  of  knee-joint  or  hip-joint;  paralysis, 
from  some  serious  disease,  such  as  infantile  paralysis, 
meningitis,  or  diphtheria. 


HEALTH  GRADING  S3 

Mental  conditions 

A  child  who  is  two  years  or  more  retarded  in  school, 
who  does  not  play  normally,  or  who  is  not  mentally 
alert,  should  always  be  suspected  of  being  mentally 
deficient.  He  should  be  tested  by  the  Binet  method.1 
It  is  necessary  to  distinguish  between  merely  dull  and 
mentally  deficient  children.  Many  mentally  deficient 
children  show  none  of  the  physical  signs  of  such  a  con- 
dition, and  may  be  the  best-looking,  children  in  the 
class.  Be  careful  not  to  overestimate  the  intelligence 
of  the  old,  mature  child  who  is  two  or  three  years  re- 
tarded, even  though  he  does  fairly  good  work  in  a 
class  of  much  younger,  less  mature  children.  He  must 
be  judged  by  the  ability  of  children  of  his  own  age, 
and  not  by  children  younger  than  himself. 

Nervous  conditions 

Stammering  is  nearly  always  a  nervous  condition, 
and  is  not  usually  due  to  physical  defects.  Nail-biting 
is  almost  never  a  mere  habit,  but  is  caused  by  an  un- 
stable condition  of  the  nervous  system.  Spasmodic 
movements  should  always  be  carefully  observed,  as 
they  often  indicate  St.  Vitus'  dance  or  habit-spasms. 
True  hysteria  is  very  seldom  observed  in  school  chil- 
dren. General  nervousness  is  indicated  by  a  lack  of' 
repose,  too  much  emotion,  inability  to  keep  quiet, 
etc.,  and  may  be  due  to  any  of  a  large  number  of 
causes.  Sometimes  the  home  conditions  will  offer  the 
1  See  p.  105. 


84  HEALTH  WORK  IN  THE  SCHOOLS 

explanation.  Often  the  child  is  from  a  nervous  family. 
Sometimes  the  trouble  is  due  to  bad  sexual  habits,  but 
more  often  the  sexual  habits  are  due  to  an  unstable 
nervous  system.  So-called  "bladder  trouble'*  is 
practically  always  a  sign  of  general  nervousness,  and 
usually  has  nothing  at  all  to  do  with  the  condition  of 
the  kidneys. 

Nose  and  throat 
Adenoids  are  usually  indicated  by  a  nasal  voice, 
frequent  colds,  crooked  and  prominent  teeth,  mouth- 
breathing,  and  mental  dullness.  Not  all  of  these  con- 
ditions are  always  present,  but  some  of  them  are. 
Adenoids  and  enlarged  tonsils  are  usually  associated. 

Ears 
Never  forget  the  relation  between  adenoids  and 
earache,  discharging  ears,  and  deafness. 

Eyes 
Children  with  crossed  eyes  nearly  always  have  a 
defect  of  vision,  and  the  crossed  eye  will  in  time  usu- 
ally become  blind,  or  nearly  so.  These  children  should 
have  properly  fitted  glasses  at  the  earliest  possible 
moment.  This  will  often  straighten  the  eyes  and  save 
the  sight.  Defective  eyes  are  often  indicated  by  red 
lids  or  red  eyes,  blurred  vision,  double  vision,  etc.  The 
teacher  should  test  the  sight  of  each  child  by  using 
the  Snellen  Test  Type.1 

1  The  Snellen  cards,  together  with  directions  for  their  use,  can  be 
secured  from  any  book-dealer  for  a  few  cents.  A  set  should  be  kept 
in  every  schoolroom.   See  chapter  vi,  p.  95. 

Ml 


HEALTH   GRADING  85 

Skin 

Any  sudden  eruption  should  always  be  noted  as 
possibly  indicating  a  contagious  disease,  such  as 
measles,  chickenpox,  scarlet  fever,  and  the  like.  No 
sort  of  skin  disease  should  ever  be  ignored;  its  cause 
must  be  discovered. 

Examine  the  teeth  of  the  children  yourself 

Stand  in  a  good  light,  have  the  children  file  past 
you  and  open  their  mouths  as  widely  as  possible.  Take 
a  quick  look  at  all  of  the  teeth  and  make  a  note  of 
each  child  who  has  defective  teeth.  It  is  not  neces- 
sary to  note  the  number  of  such  teeth,  for  every  de- 
fective tooth  ought  to  receive  immediate  attention. 

Some  general  observations 

Try  to  discover  what  children  always  have  coated 
tongues.  This  is  most  always  due  to  constipation. 
Try  to  correct  this  condition  among  children,  as  it  is 
extremely  common  and  usually  receives  very  little 
attention  at  home. 

Attempt  to  learn  the  home  habits  of  the  children 
under  your  care.  You  will  be  surprised  to  learn  how 
many  keep  very  late  hours.  Try  to  learn  the  cause  for 
this:  Try  to  learn  how  many  children  eat  candy  every 
day.  Talk  to  them  about  bathing  habits,  and  learn 
what  their  habits  actually  are  in  this  respect.  Make 
a  list  of  the  children  who  live  in  families  where  there 


86  HEALTH  WORK  IN  THE  SCHOOLS 

is  chronic  sickness,  and  discover  what  the  sickness  is. 
Always  be  on  the  alert  for  signs  of  children's  conta- 
gious diseases  when  they  first  manifest  themselves. 
Use  the  information  obtained  by  the  Outline  for 
practical  teaching  in  matters  of  hygiene,  in  your  parti- 
cular room.  This  will  furnish  a  more  effective  basis 
for  useful  health  teaching  than  anything  else. 

Part  III:  Some  Results  secured  by  the  Outline 
for  the  Health  Grading  of  School  Children 

In  order  to  test  the  usefulness  of  the  method  for 
health  grading  of  school  children,  and  also  to  demon- 
strate to  teachers  actual  conditions  in  their  rooms, 
thirty-three  grades  were  questioned  on  Part  I  of  the 
Outline. 

In  obtaining  the  answers,  the  physician  asked  the 
questions,  one  at  a  time,  of  the  entire  roomful  of 
children,  their  answers  being  indicated  by  rising.1 
At  this  time  no  individual  names  were  recorded.  The 
tabulated  results  which  appear  below  are  remarkable 
not  only  as  indicating  the  number  of  physical  handi- 
caps which  may  easily  be  discovered,  but  also  in  re- 
spect to- the  uniformity  found  in  different  schools  of 
the  same  and  widely  separated  towns  and  cities.  No 
one  can  possibly  read  these  results,  so  easily  obtained, 
and  remain  unconvinced  of  the  seriousness  of  the  de- 

1  To  avoid  suggestion  it  is  better  to  secure  the  data  by  question- 
ing each  pupil  privately  whenever  time  permits.  If  this  is  impossi- 
ble, the  pupils  should  be  urged  to  state  the  exact  facts,  without  pay- 
ing any  attention  to  the  answers  given  by  other  children. 


HEALTH   GRADING 


87 


fects  from  which  at  least  40  to  50  per  cent  of  school 
children  suffer. 

The  accompanying  table  summarizes  the  answers  to 
"survey"  questions  in  ten  cities  and  towns  of  Min- 

TABLE  I 

Answers  to   "Survey"  Questions  Addressed  to  3215 
Minnesota  Children 


Name  of 
Town  or  City 

.a 

03 

3 

CO 
N 

B 

la 

03 
W 

I 

2 

<n 

A 

M 

O 

SZ3 

0 

1 

u 

a 
O 

I 

IS 

a 

a 

"o 

2 

E 

a? 

c 

43 
CO 

i 

o 

3 

a 
o 

tx 
a 

a 

B 

o 

u 

Total  Pupils 

187 

582 

299 

247 

210 

272 

425 

278 

590 

125 

Coffee 

159 

353 

238 

159 

151 

221 

364 

175 

526 

87 

75+ 

Tea 

65 

121 

90 

80 

83 

51 

213 

X 

78 

52 

29+ 

No  .Ventilation 
in  bed-room 

104 

222 

180 

124 

122 

174 

207 

50 

221 

54 

45 

Headache 

43 

139 

61 

81 

29 

50 

86 

80 

116 

41 

22 

Poor  Vision 

33 

97 

37 

57 

27 

25 

42 

52 

53 

18 

13 

Earache 

12 

80 

35 

32 

18 

26 

31 

28. 

34 

9 

10— 

Running  Ear 

5 

27 

10 

11 

5 

9 

12 

4 

7 

1 

3— 

Poor  Hearing 

10 

43 

21 

10 

10 

7 

16 

9 

4 

6 

4 

Nasal  Obstuction 

8 

68 

29 

19 

31 

14 

32 

X 

14 

11 

6+ 

Toothache 

43 

258 

57 

75 

73 

73 

151 

55 

129 

27 

30- 

Double  Vision 

8 

20 

5 

11 

X 

5 

13 

11 

3 

X 

2.5 

Common 
Tooth  Brush 

25 

X 

45 

11 

X 

7 

84 

X 

33 

12 

9+ 

Bad  Teeth 

X 

298 

137 

131 

60 

195 

233 

94 

370 

59 

50 

88  HEALTH  WORK  IN  THE  SCHOOLS 

nesota,  in  which  3215  children  are  included.1  In  a  few 
cases  certain  questions  were  omitted.  This  is  indi- 
cated in  the  table  by  crosses,  X.  It  will  be  noted  that 
the  data,  on  the  whole,  are  remarkably  uniform. 

Tabulation  of  the  replies  by  grades  showed  that  as 
children  pass  beyond  the  sixth  grade  nearly  all  the 
conditions  improve.  This  includes  earlier  hours  for 
retiring  (because  parents  take  young  children  out 
with  them  at  night),  far  better  ventilation  in  bed- 
rooms, and  a  better  condition  of  teeth  due  to  the 
completion  of  second  dentition. 

Of  2500  grade  children  questioned,  75  per  cent  make 
a  breakfast  entirely,  or  almost  entirely,  of  starchy 
foods.  Only  15  per  cent  of  the  2500  have  fruit  of  any 
kind  for  breakfast.  The  following  are  the  usual  break- 
fasts of  these  children:  — 

1.  Coffee,  bread  and  butter. 

2.  Coffee  and  oatmeal. 

3.  Coffee  and  some  other  cereal. 

4.  Coffee  and  hot  cakes. 

5.  Coffee  alone. 

6.  Coffee  and  biscuits. 

7.  Coffee  and  coffee-cake. 

8.  Bread  and  butter  alone. 

Is  it  any  wonder  that  nearly  23  per  cent  have  fre- 
quent headaches? 

1  At  a  later  date  6000  additional  children  were  questioned  with 
practically  the  same  results. 


^     *WL 


HEALTH   GRADING  89 


REFERENCES 

1.  Altschul,  Dr.  Theodore:  "Cooperation  between  Doctor  and 
Teacher."  Proceedings,  Third  Internafl.  Cong.  Sch.  Hyg.,  1910, 
vol.  ii,  p.  199/. 

2.  DelSarde,  Dr.:  "Collaboration  du  medecin  et  du  maltre  en 
hygiene  scolaire."  Ibid.,  p.  382/. 

*3.  Hayward,  Dr.  John  A.:  "Cooperation  of  the  Teacher,  Doctor 
and  Nurse  in  Medical  Inspection."  Proceedings,  Second  Inter- 
nat'l Cong.  Sch.  Hyg.,  1907,  pp.  469  ff.  (See  same  volume, 
p.  435.) 

*4.  Hoag,  Dr.  E.  B.:  "The  Teacher's  Relation  to  Health  Super- 
vision in  Schools."   Bull.  Am.  Acad.  Med.,  June,  1912. 

*5.  Hoag,  Dr.  E.  B.:  "Organized  Health  Work  in  the  Schools," 
Bull,  U.S.  Bur.  Ed.,  1913,  pp.  55. 

*6.  Standish,  Dr.  Myles:  "Should  Examinations  of  Eyes  of  School 
Children  be  conducted  by  Teachers  or  by  School  Physicians?" 
Proceedings,  Fifth  Am.  Cong.  Sch.  Hyg.,  1911,  pp.  98-101. 
7.  Walsh,  Dr.  S.  B.:  "The  School  Teacher  as  a  Factor  in  Public 
Health."  School  Hygiene,  1912,  pp.  208-13. 


CHAPTER  VI 

A    DEMONSTRATION    CLINIC  FOR    INSTRUCTION    IN 
THE  OBSERVATION  OF  DEFECTS 

For  the  purpose  of  instructing  teachers  and  school 
nurses  the  "Demonstration  Clinic"  has  proved  of  the 
greatest  possible  assistance.  From  fifty  to  one  hun- 
dred and  fifty  pupils  from  various  grades,  preferably 
the  third,  fourth,  and  fifth,  are  assembled  in  the  pres- 
ence of  all  the  teachers  (and  school  nurses,  if  there 
are  any).  The  physician  in  charge  of  the  "clinic" 
then  proceeds  to  demonstrate  the  health  conditions 
of  the  pupils  present.  To  indicate  exactly  how  the 
demonstration  clinic  may  be  carried  out,  a  verbatim 
report  is  given  here  of  one  held  by  Dr.  Hoag,  in  a 
small  Minnesota  city,  with  eighty-five  children  from 
the  third,  fourth,  fifth,  and  sixth  grades  present.  A 
summary  of  sixteen  other  demonstration  clinics,  held 
in  Minnesota  cities  and  villages,  is  also  given  in  a 
table  at  the  end  of  the  report. 

Verbatim   Report    of  a   Demonstration  Clinic 

Object  of  the  clinic 

The  object  of  this  demonstration  is  to  show  teachers  how 
easy  it  is  to  detect  the  ordinary  physical  defects  from  which 
children  suffer.  Most  people  have  the  idea  that  it  is  neces- 
sary to  have  an  expert  go  into  the  schools  to  find  these  handi- 
caps, but  any  teacher,  after  a  little  instruction,  can  discover 


A  DEMONSTRATION  CLINIC  91 

the  ordinary  handicaps  almost  as  well  as  any  expert  can. 
Only  the  larger  places  in  the  country  have  any  health  super- 
vision of  schools  that  is  really  worthy  of  the  name,  and  the 
reason  is  that  they  think  only  experts  can  do  the  work.  Now, 
as  a  matter  of  fact,  all  the  schools  everywhere  need  to  have 
this  sort  of  health  work,  and  in  many  instances  the  only  way 
they  can  obtain  it  at  present  is  to  have  the  teachers  them- 
selves attack  the  problem. 

The  ordinary  handicaps  that  we  find  in  children  are  about 
the  same  everywhere  we  go,  whether  it  is  in  a  California  town 
or  in  a  Minnesota  town;  and  the  proportion  of  the  defects 
that  we  find  is  practically  the  same  everywhere;  so  that  I 
could  say  in  advance  in  this  place  just  about  how  many  cases 
of  adenoids  will  be  found,  how  many  cases  of  visual  defects, 
how  many  of  chronic  earache,  how  many  of  headache,  how 
many  of  defective  teeth,  etc. 

We  are  not  looking  for  sick  children,  as  that  word  is  ordi- 
narily used,  and  we  do  not  often  observe  sick  children  in  the 
schools,  but  we  do  find  a  very  considerable  number  who  have 
physical  or  mental  handicaps  which  interfere  with  their 
school  progress,  and  it  is  these  handicaps  which  we  wish  to 
discover  and  if  possible  have  corrected.  We  do  not  realize, 
for  instance,  that  a  large  number  of  children  suffer  from 
chronic  headache  who  never  say  a  word  about  it  unless  they 
are  questioned.  They  take  it  as  a  matter  of  course  and  be- 
come accustomed  to  it.  We  do  not  realize  that  a  very  con- 
siderable proportion  of  children  have  more  or  less  chronic 
earache,  and  yet  never  mention  it  unless  the  earache  is  so 
bad  that  they  cannot  sleep  at  night.  We  do  not  realize  that  a 
large  number  of  children  have  toothache,  some  of  them  most 
of  the  time;  that  they  have  visual  defects  so  severe  in  many 
cases  that  they  do  not  read  comfortably  or  well.  They  suffer 
from  various  handicaps  of  this  sort  and  never  say  anything 
about  it,  simply  because  they  are  accustomed  to  the  condi- 
tion and  very  often  know  no  other.  They  have  no  standard 
of  comparison.  Children  in  the  main  never  complain  about 
their  physical  handicaps  unless  they  are  so  serious  as  actually 
to  make  them  sick,  and  this  is  a  point  which  we  must  always 
remember  in  dealing  with  them. 


92         HEALTH  WORK  IN  THE  SCHOOLS 

Purposes  and  methods  of  work 

Now  what  I  want  to  do  here  this  afternoon  is  to  ask  these 
eighty-five  children  some  very  simple,  commonplace  ques- 
tions, just  as  I  would  like  to  have  you  do  with  your  children 
in  the  various  grades,  and  the  answers  to  these  questions  will 
indicate  pretty  accurately  the  sort  of  physical  handicaps 
which  are  present.  I  shall  have  to  ask  the  questions  of  the 
whole  group  and  not  take  down  any  individual  names,  but 
teachers  in  gathering  such  information  ought  to  record  each 
child's  examination  separately  and  make  it  a  permanent 
school  record. 

As  a  matter  of  fact,  at  least  twenty-five  per  cent  of  school 
children  have  visual  defects  of  some  kind  or  another.  These 
are  ordinarily  discovered  by  the  use  of  the  test-type  card,  but 
without  any  card  or  apparatus  of  any  sort  you  can  still  dis- 
cover a  very  considerable  number  of  eye  defects  by  a  simple 
question.  In  order  to  demonstrate  this  point,  I  am  going  to 
ask  these  children  the  question  and  they  will  answer  by  ris- 
ing, and  the  question  is  this  —  "Now,  children,  I  want  you 
to  listen  carefully,  and  do  not  answer  until  I  am  all  through. 
How  many  of  you  notice  when  you  read  in  your  books  that 
the  print  is  hard  to  see,  or  that  it  often  looks  dim,  or  per- 
haps crooked,  or  that  you  see  two  letters  instead  of  one,  or 
two  lines  instead  of  one,  or  that  in  some  way  you  find  it 
hard  to  read  ?  " 

The  number  of  children  who  are  standing  is  eighteen,  and 
we  will  now  try  to  discover,  by  some  further  questions, 
whether  these  children  really  know  what  they  are  talking 
about  or  not.  The  children  will  give  answers  of  a  certain 
type,  and  these  answers  will  be  exactly  such  as  children  give 
in  other  places  and  in  almost  exactly  the  same  words,  for  the 
simple  reason  that  they  have  the  same  defects  that  children 
in  other  places  have.  I  want  to  ask  the  teachers  to  please 
listen  carefully  to  the  responses  which  are  made  when  we  ask 
the  children  about  their  eyes. 

Condition  of  the  eyes 

I  am  going  to  ask  this  boy  how  the  print  looks  when  he 
reads  in  his  book.   He  replies  that  "it  looks  blurred."  The 


A  DEMONSTRATION  CLINIC  93 

next  boy  says  that  the  print  "  looks  dark,"  but  I  am  going  to 
ask  him  what  he  means  by  "  dark."  He  replies  that  he  cannot 
see  it,  and  I  notice  that  he  is  troubled  with  what  is  technically 
called  "squint  eye,"  or  crossed  eye.  Let  us  ask  him  if  he  ever 
sees  letters  or  lines  double.  He  says  that  a  good  deal  of  the 
time  he  does  see  letters  and  lines  double,  which  is  nearly  al- 
ways the  case  in  instances  of  this  sort.  Cases  like  this  ought 
always  to  receive  the  promptest  kind  of  attention,  because 
the  vision  in  the  crossed  eye  deteriorates  rapidly,  and  in 
many  cases,  if  glasses  are  not  properly  fitted  before  the  child 
is  eight  or  nine  years  of  age  (or  even  earlier),  the  vision  has 
already  gone  to  the  extent  of  fifty  to  one  hundred  per  cent. 

I  shall  test  this  boy's  vision  right  at  this  point,  and  see  how 
much  he  still  retains  in  the  crossed  eye.  I  have  tested  him  by 
first  standing  away  about  twenty  feet  and  holding  up  my 
fingers  and  having  him  tell  me  the  number  he  sees.  He  fails 
absolutely  at  a  distance  of  twenty  feet;  then  he  fails  at  a  dis- 
tance of  fifteen  feet  and  he  continues  to  fail  until  I  get  within 
nine  feet  of  him.  At  this  distance  and  in  a  strong  light  he 
can  tell  how  many  fingers  are  held  up  in  front  of  the  crossed 
eye.  This  shows  that  his  vision  has  very  greatly  deteriorated 
in  this  eye.  If  glasses  had  been  properly  fitted  to  this  boy's 
eyes  several  years  ago,  most  of  the  sight  could  have  been 
saved.  This  illustrates  very  well  how  absolutely  necessary  it 
is  to  correct  the  vision  in  any  child  who  has  a  tendency  to 
crossed  eye.  If  the  glasses  are  put  on  early  the  eyes  will,  in 
the  majority  of  cases,  be  straightened  without  any  operation, 
and  most  of  the  vision,  if  not  all  of  it,  will  be  retained.  I  have 
just  asked  the  boy  how  long  he  has  been  wearing  glasses.  He 
is  eleven  years  old  and  he  says,  "only  a  little  while."  The 
trouble  is  that  the  glasses  were  procured  too  late. 

I  have  just  asked  a  little  girl  how  the  print  looks  to  her,  and 
her  reply  is  that  when  she  looks  in  her  book  she  sees  "two 
lines  just  the  same."  This  is  another  case  of  "squint  eye."  I 
will  also  test  her  eyes  in  the  same  manner  that  I  did  the  boy's. 
This  child's  vision  is  exactly  the  same  as  in  the  case  of  the 
boy.  She  reads  fingers  at  a  distance  of  about  nine  or  ten  feet. 

The  next  child  that  I  question  about  her  eyes  says  that 
the  print  "looks  blurred,  and  runs  all  together." 

The  next  little  girl  replies  when  I  question  her  about  the 
print  that  "it  blots,"  which  is  a  perfectly  characteristic 


94  HEALTH  WORK  IN  THE  SCHOOLS 

answer,  given  by  a  great  many  children  in  different  places, 
and  has  a  definite  significance  to  anybody  who  understands 
the  eye. 

The  child  now  before  me  says  the  print  "looks  light,"  and 
by  that  she  means  that  it  appears  dim  and  is  not  sharp  and 
clear-cut.  She  probably  has  a  case  of  astigmatism. 

Still  another  child  replies  that  the  print  "looks  crooked," 
which  is  also  a  very  common  reply. 

The  next  child  has  just  told  me  what  I  suppose  one  hun- 
dred children  at  least  have  said.  She  remarks  that  the  print 
"looks  upside  down."  By  that  she  does  n't  mean  that  it  is 
actually  upside  down,  but  that  it  is  turned  around  a  good 
deal. 

This  little  girl  now  before  me  gives  a  very  interesting  and 
definite  answer.  She  says,  "The  print  looks  like  it  was  n't 
there  and  I  am  always  skipping  words."  There  is  no  ques- 
tion at  all  about  the  fact  that  she  has  a  definite  visual  defect. 

The  boy  I  am  now  questioning  says  the  lines  "look 
double."  He  has  what  we  call  "muscular  unbalance." 

The  next  child  says  that  after  he  has  looked  at  the  book  a 
little  while  he  sees  "two  lines  instead  of  one." 

Another  child  says  that  some  of  the  letters  look  big  and 
some  look  small." 

This  child  whom  I  am  now  questioning  gives  another  very 
interesting  answer,  which  is  definite  and  significant.  He  says 
that  "some  of  the  words  look  light,  and  some  of  the  words 
look  dark,"  which  is  just  as  clear  a  diagnosis  of  astigmatism 
as  can  be  given  by  any  doctor. 

The  little  girl  now  being  questioned  says  that  the  words 
"look  blotted,  and  some  look  lighter  than  others,"  and  "I 
often  mispronounce  words,  because  I  am  not  sure  what  the 
words  are." 

The  next  child  says,  "When  I  study,  the  words  all  run 
together,  and  then  it  gets  black." 

Here  is  a  boy  who  tells  me  that  he  always  reads  the  same 
line  twice  and  he  does  not  know  why  he  does  it,  and  when  he 
reads  at  home  in  "magazines  and  things,"  he  gets  a  head- 
ache.   This  is  a  very  clear  diagnosis  of  eye-strain. 

The  next  boy  says  "the  words  look  dim  and  shaky."  A 
great  many  children  complain  that  the  words  move  or  jump. 

I  will  not  repeat  all  of  the  remainder  of  the  responses  which 


A  DEMONSTRATION  CLINIC  95 

the  children  will  give,  but  will  pass  on  in  the  examination 
hurriedly. 

What  I  want  you  teachers  to  notice  particularly  is  that, 
with  two  exceptions,  all  of  the  children  of  the  eighteen  ques- 
tioned give  prompt  and  definite  replies  as  to  how  the  print 
looks  to  them,  and  that  their  answers  give  evidence  that 
there  is  some  real  defect  present.1  Two  of  the  answers  were 
very  vague,  and  the  children  merely  repeated  what  they 
heard  other  children  say.  You  can  always  be  sure  that  in 
such  instances  there  is  little  or  no  trouble.  If  a  child  has  a 
visual  defect  that  amounts  to  very  much  it  can  ordinarily 
be  brought  out  by  the  sort  of  response  which  he  gives  to  the 
question  about  his  eyesight. 

Testing  the  vision 

We  will  now  make  a  short  demonstration  of  how  to  test 
the  vision  by  use  of  the  Snellen  Test  Card. 

In  order  to  make  this  test,  place  the  eye-test  card  in  a 
good  light,  making  sure  that  the  child  is  not  facing  the 
light.  Measure  off  a  distance  of  20  feet.  Hang  the  card  on 
the  wall  nearly  on  a  level  with  the  child's  eyes.  Cover  one 
eye  with  a  piece  of  cardboard  or  an  envelope.  Never  allow 
anything  to  press  on  the  eye,  or  it  will  interfere  with  the 
vision  for  several  moments.  Testing  one  eye  at  a  time  in  this 
manner,  ask  the  child  to  read  the  line  on  the  card  which  is 
marked  "20  feet";  that  is,  he  ought  to  read  the  20-foot  line 
at  a  distance  away  of  20  feet.  If  he  gets  a  majority  of  the 
letters,  we  pass  him  on  the  test.  If  he  fails  to  get  a  majority 
of  the  letters,  we  ask  him  to  take  the  next  line,  which  he  should 
read  at  30  feet.  If  he  fails  to  get  the  majority  of  the  letters  in 
this  line,  try  him  successively  with  each  line  above  until  you 
find  a  line  which  he  can  read.  We  will  say,  for  example,  that 
he  reads  the  line  which  is  marked  "40  feet";  that  is,  it  is  a 
line  which  he  ought  to  read  at  a  distance  of  40  feet,  but  as  a 
matter  of  fact,  he  is  only  standing  20  feet  away.  Therefore 
his  vision  is  20/40,  or  one  half  what  it  ought  to  be.  The  dis- 
tance which  the  child  is  standing  away  from  the  card  repre- 
sents the  numerator  of  the  visual  fraction,  and  the  line  which 

1  These  children  had  been  selected  by  the  demonstrator  because 
all  of  them  presented  objective  signs  of  visual  defect. 


96  HEALTH  WORK  IN  THE  SCHOOLS 

he  reads  on  the  card  represents  the  denominator.  Children 
have  a  tendency  to  transpose  letters,  but  this  is  of  no  conse- 
quence and  no  attention  should  be  paid  to  it.  If  they  are  very 
slow  in  reading  the  letters,  it  usually  indicates  some  eye 
defect,  even  though  they  read  them  correctly. 

I  will  now  test  the  eyes  of  the  boy  who  said  a  few  moments 
ago  that  he  often  sees  the  letters  double.  I  find  that  he  does 
not  see  all  of  the  letters  in  the  20-foot  line  and  complains  that 
they  look  blurred.  He  reads  the  30-foot  line  without  any 
difficulty,  which  gives  him  a  vision  of  about  20/30. 

I  am  now  testing  another  child  who  said  that  the  letters 
run  together.  She  reads  the  30-foot  line  without  any  diffi- 
culty and  a  majority  of  the  letters  in  the  20-foot  line;  appar- 
ently she  only  has  a  mild  degree  of  eye  defect. 

The  next  child  reads  a  majority  of  the  letters  in  the  20-foot 
line,  but  fails  on  one  or  two  and  says  that  they  look  slanting. 
Here,  again,  is  apparently  a  rather  mild  degree  of  eye  defect. 

This  next  little  girl  did  not  respond  originally,  but  never- 
theless she  has  trouble.  She  cannot  read  the  last  line.  She 
fails  to  read  both  the  20-foot  and  30-foot  line  with  the  right 
eye,  and  testing  her  eyes  with  each  line  successively,  I  dis- 
cover that  the  100-foot  line  is  the  first  she  can  read.  This 
little  girl's  vision  is  then  about  20/100.  The  child  says  that 
the  print  looks  all  right  to  her  when  she  is  reading,  but  the 
teacher  remarks  that  she  always  has  to  hold  the  book  near 
her  eyes.  Of  course  she  has  a  very  high  degree  of  eye  defect, 
probably  myopia,  shortsight,  and  she  ought  to  have  glasses 
at  the  earliest  possible  moment,  before  the  eyes  deteriorate 
any  more  than  they  have  already. 

In  testing  the  vision  of  the  young  child  who  has  not  yet 
learned  to  read,  it  is  best  to  make  use  of  the  McCallie  test.  It 
consists  of  a  series  of  cards  about  5  inches  square  on  which 
are  the  pictures  of  a  boy,  a  girl,  and  a  bear.  They  are  playing 
the  game  of  ball,  and  the  ball,  which  is  represented  by  a  small 
black  dot,  should  be  seen  by  the  normal  eye  at  a  distance  of 
20  feet.  By  changing  the  cards  frequently  it  is  easy  to  dis- 
cover whether  or  not  the  child  can  really  determine  who  has 
the  ball.  If  he  does  not  see  the  dot  at  a  distance  of  20  feet, 
then  you  gradually  walk  toward  him  until  he^  succeeds  in 
seeing  it  and  then  you  estimate  from  this  about  what  his 
visual  error  is. 


A  DEMONSTRATION  CLINIC  97 

Other  eye  defects 

Teachers  ought  not  only  to  observe  and  record  defects  of 
vision,  but  ought  also  to  make  note  of  congested  eyes,  watery 
eyes,  sties,  and  granulated  lids.  None  of  these  conditions  are 
normal,  and  all  of  them  should  receive  attention.  The  seri- 
ous eye  disease  known  as  "trachoma"  is  contagious,  and 
very  difficult  to  cure.  It  is  observed  chiefly  among  children 
from  the  slums  who  have  recently  arrived  from  Europe.  It 
is  also  rather  common  among  the  Indians  and  Japanese. 
It  is  difficult  for  any  but  an  expert  to  recognize  this  disease, 
but  one  should  suspect  it  when  any  children  of  the  class  in- 
dicated above  have  eye  conditions  described  as  follows :  — 

(1)  Inflammation:  this  is  not  very  intense,  but  there  is 
considerable  swelling  of  the  lids,  an  aversion  to  light  and  a 
flowing  of  tears. 

(2)  The  outer  surface  of  the  eyeball  becomes  roughened. 

(3)  The  inner  surface  of  the  eyelids  is  covered  with  small 
granules  not  unlike  boiled  sago  grains  in  appearance,  and 
this  produces  what  is  called  granular  eyelids. 

A  sudden  redness  of  the  eyes,  with  more  or  less  sensitive- 
ness to  light,  particularly  when  accompanied  by  what  ap- 
pears to  be  a  cold,  should  always  cause  the  suspicion  of 
measles.  Sometimes  pink-eye  starts  in  this  manner. 

Adenoids 

I  want  to  show  you  now  how  easy  it  is  to  detect  the  chil- 
dren who  are  suffering  from  adenoids.  I  can  go  through  any 
room  and  in  most  instances  can  detect  nearly  all  the  adenoid 
children  within  two  or  three  minutes  after  I  have  been  in  the 
room,  and  what  1  can  do  the  teacher  ought  to  be  able  to  do 
just  as  easily,  because  she  is  perfectly  familiar  with  the  chil- 
dren. I  shall  select  a  boy  whom  I  have  never  seen  before, 
a  boy  who  looks  to  me  as  if  he  had  adenoids.  Then  we  will 
test  him  to  see  if  he  really  has  them.  My  first  reason  for  se- 
lecting this  boy  is  because  he  has  a  tendency  to  breathe  with 
his  mouth  open.  In  making  the  examination  I  note  at  once 
that  the  lower  teeth  cut  considerably  inside  the  upper  teeth 
and  that  the  upper  teeth  are  prominent,  which  is  very  often 
the  case  where  a  child  has  breathed  through  his  mouth  for 


98  HEALTH  WORK  IN  THE  SCHOOLS 

one  year  or  more.  In  other  words,  mouth-breathing  has  a 
tendency  to  deform  the  jaws,  so  that  the  teeth  in  the  upper 
jaw  are  either  crooked  or  prominent,  or  both.  Or,  to  put  it 
another  way,  probably  in  ninety -five  per  cent  of  all  the  cases 
where  one  notes  crooked  and  prominent  teeth,  mouth-breath- 
ing has  occurred.  Adenoids  tend  to  produce  more  or  less 
deformity  of  the  bones  of  the  face.  Thumb-sucking  and  the 
early  loss  of  the  first  teeth  also  have  a  tendency  to  produce 
crooked  teeth  and  other  deformities  of  the  jaws. 

The  first  thing  that  I  am  going  to  do  in  testing  this  child  is 
to  ask  him  to  talk  a  little,  because  I  want  to  discover  the 
quality  of  his  voice.  The  boy's  voice  proves  to  be  distinctly 
nasal  in  quality,  and  by  giving  these  words  which  you  have 
just  heard  him  pronounce,  "nine,"  "ninety-nine,"  "nine 
hundred  and  ninety-nine,"  you  at  once  bring  out  this  nasal 
quality  of  the  voice.  Now  there  are  in  general  only  two  rea- 
sons why  a  child  has  a  nasal  voice.  One  is  that  he  has  an 
acute  cold,  and  the  other  is  that  he  has  an  obstruction  in  his 
nose,  usually  due  to  adenoids.  This  boy  has  no  cold;  so  rea- 
soning from  what  I  have  said,  he  has  adenoids.  And  you  can 
be  sure  in  practically  every  case  that,  barring  a  cold,  a  nasal 
voice  in  a  school  child  means  just  one  thing,  and  that  is  ade- 
noids. If  in  addition  to  this  you  can  discover  that  the  child 
sleeps  with  his  mouth  open  and  has  a  tendency  to  snore,  you 
may  be  quite  sure  that  you  have  a  case  of  adenoids.  I  have 
just  asked  this  boy  if  he  snores  in  his  sleep  and  he  says, 
"Yes."  His  mother  tells  him  that  he  does. 

In  reply  to  my  question  as  to  how  his  mouth  feels  when  he 
wakes  up  in  the  morning  he  says  that  his  "mouth  feels  dry," 
and  the  reason,  of  course,  is  that  he  has  breathed  all  night 
with  his  mouth  wide  open.  Mouth-breathing  is  never  nor- 
mal. 

The  next  boy  I  have  selected  for  examination  says  that  he 
has  had  an  operation  on  his  nose  and  throat,  and  as  a  matter 
of  fact  I  note  that  the  tonsils  have  been  removed.  Probably 
the  adenoids  were  also  removed,  but  in  any  event  there  is 
some  adenoid  tissue  still  present.  The  adenoid  tissue  may 
not  have  been  completely  removed  or  it  may  have  returned, 
because  not  infrequently  adenoids  come  back  a  second,  and 
sometimes  even  a  third  time.  There  is  only  one  thing  to  do 
in  these  cases,  and  that  is  to  have  the  operation  repeated  and 


SladeWOS 


Why  adenoid  children  cannot  breathe. 


Three  views  of  an  adenoid  face. 
ADENOIDS 


CROSSED   EYE   AND   OBSTRUCTED   BREATHING 
Courtesy  Dr.  N.  H.  Bullock,  San  Jos6,  Cal. 


A  DEMONSTRATION  CLINIC  99 

all  the  tissue  removed.  This  child's  facial  bones  have  been 
somewhat  deformed  by  mouth-breathing  before  his  opera- 
tion. 

Hearing,  and  ear  troubles 

Teachers  ought  always  to  be  suspicious  of  ear  trouble 
where  there  are  adenoids,  because  adenoid  tissue  has  a  tend- 
ency to  cause  trouble  with  the  ears.  For  this  reason  I  am 
going  to  test  this  boy's  hearing,  to  see  whether  or  not  it  is 
good.  I  suspect  that  he  is  somewhat  deaf,  because  he  has 
already  asked  me  to  repeat  questions  a  number  of  times.  To 
test  the  hearing,  one  of  the  best  ways  is  to  use  the  watch.  You 
want  to  determine  how  far  you  can  hear  your  own  watch  in  a 
certain  room.  You  cannot  state  in  advance  how  far  a  watch 
ought  to  be  heard.  Sometimes  people  say  to  me,  "How  far 
should  a  watch  be  heard?"  Of  course,  it  goes  without  saying 
that  it  depends  upon  the  watch,  and  upon  the  room  in  which 
you  are  giving  the  test.  To  determine  this  point,  take  your 
own  watch  in  a  given  room  and  see  how  far  you  can  hear  it, 
making  sure  that  your  own  hearing  is  good  to  begin  with; 
then  let  this  distance  be  used  as  the  norm.  I  can  hear  my 
own  watch  in  this  room  at  arm's  length,  which  is  close  to 
two  and  a  half  feet.  In  testing  the  hearing,  always  cover  the 
child's  eyes  with  one  hand.  This  boy's  hearing  is  reduced  in 
his  right  ear  a  little  more  than  one  half.  In  making  the  test 
be  sure  that  the  child  is  not  drawing  on  his  imagination,  and 
in  order  to  determine  this  point  occasionally  hold  the  watch 
behind  you  and  ask  the  child  if  he  hears  it.  The  hearing  in 
the  left  ear  proves  to  be  about  two  thirds  normal. 

The  boy  says  that  he  has  never  had  scarlet  fever,  nor,  as 
far  as  he  knows,  any  serious  sickness.  This  is  pretty  good 
evidence  that  the  defective  hearing  is  not  due  to  any  acute 
infectious  disease,  as  is  sometimes  the  case,  and  that  the  de- 
crease in  hearing  is  due  entirely  to  adenoids.  This  is  cer- 
tainly an  illustration  of  the  fact  that  adenoids  ought  to  be 
taken  care  of  early.  In  a  very  large  number  of  cases  adenoids 
result  in  seriously  defective  hearing.  Every  child  with  ade- 
noids ought  to  have  his  ears  examined.  Every  child  who  has 
earache  or  running  ears  ought  to  be  examined  for  adenoids. 
In  other  words,  nearly  all  the  ear  trouble  in  children  origi- 
nates in  the  nose  and  throat.  The  trouble  is  not  primarily 
in  the  ear,  but  in  the  nose  and  throat.  Sometimes  it  is  be- 


100        HEALTH  WORK  IN  THE  SCHOOLS 

cause  the  adenoid  tissue  which  is  situated  behind  the  soft 
palate  grows  over  the  opening  of  the  eustachian  tube,  which 
as  you  know  leads  to  the  middle  ear  and  ventilates  it. 
Sometimes  the  ear  trouble  results  from  a  catarrh  of  the  nose 
and  throat,  due  either  to  adenoids  or  diseased  tonsils,  and 
the  inflammation  travels  through  the  eustachian  tube  to  the 
middle  ear  and  sets  up  a  similar  inflammation  here.  So  never 
forget  that  there  is  a  very  close  and  intimate  relation  be- 
tween ear  troubles  and  those  of  the  nose  and  throat,  and 
that  most  ear  defects  are  avoidable. 

The  whisper  test  of  hearing 

If  you  ever  have  any  reason  to  suspect  that  the  answers  of 
a  child  are  incorrect,  when  he  is  being  tested  with  the  watch- 
tick,  it  is  a  very  easy  matter  to  test  him  with  the  whispered 
voice.  Place  him  at  least  twenty  feet  away,  cover  your  own 
lips  with  a  piece  of  paper,  so  that  he  cannot  see  their  move- 
ment, and  then  give  him  commands  in  a  whisper.  If  he  fails 
to  execute  the  commands  you  may  be  perfectly  sure  that  he 
does  not  hear  well,  provided  a  normal  child  already  tested  at 
the  same  distance  does  execute  the  same  commands  when 
you  use  the  same  intensity  of  whisper.  It  is  always  a  good 
procedure  to  use  both  the  watch  and  the  whispered  voice 
test.  In  the  main  it  is  safe  to  say  that  eight  per  cent  of  the 
children  in  schools  have  adenoids,  that  five  to  seven  per  cent 
of  the  children  are  partially  deaf  when  tested  with  rough 
methods,  and  that  nearly  fifteen  per  cent  of  them  would  be 
found  to  have  defective  hearing  if  they  were  accurately  tested 
by  a  physician.  I  want  to  repeat  here  that  almost  all  of  this 
trouble  is  due  to  neglected  adenoids  or  diseased  tonsils. 

The  teeth 

In  examining  the  teeth  of  children,  stand  in  a  good  light 
with  your  back  toward  the  window,  and  have  the  children 
form  a  line.  Let  them  march  past  you,  and  as  each  child 
comes  in  front  of  you  have  him  open  his  mouth  just  as  wide 
as  possible.  Put  one  hand  on  the  top  of  the  head  and  the 
other  on  the  chin,  and  the  mouth  will  open  wide.  Note 
whether  or  not  the  child  has  any  bad  teeth,  and  if  he  has, 
make  a  record  of  it.   It  is  a  general  impression  among  par- 


A  DEMONSTRATION  CLINIC  101 

ents  and  teachers  that  it  is  all  right  to  ignore  defective  teeth 
in  young  children, —  i.e.,  the  baby  teeth,  —  but  as  a  matter 
of  fact  it  is  more  important  to  get  the  first,  or  deciduous, 
teeth  repaired  than  it  is  the  permanent  ones.  So  any  de- 
cayed teeth,  whether  in  a  young  child  or  in  an  older  one, 
ought  to  receive  prompt  attention. 

General  health  survey 

Having  demonstrated  these  simple  procedures  in  testing 
the  eyes,  ears,  nose,  and  teeth,  we  will  now  make  a  general 
health  survey  of  the  children,  by  asking  some  questions. 

"How  many  children  here  have  a  good  deal  of  headache? 
By  that  I  mean  as  often  as  once  a  week,  or  three  times  a 
week,  or  every  day?  "  Eight  children  respond  to  this  ques- 
tion and  complain  of  more  or  less  chronic  headache.  This  is  a 
smaller  number  than  we  usually  discover.  There  are  eighty- 
five  children  present,  and  out  of  that  number  we  should  ex- 
pect to  find  fifteen  or  twenty  who  suffer  more  or  less  from 
chronic  headache. 

"How  many  children  here  have  earache  every  once  in  a 
while?"  Now  the  number  standing  is  just  about  what  we 
should  expect  to  find.  We  have  ten  children  standing,  which 
is  about  the  usual  proportion. 

"How  many  of  you  children  sometimes  have  running  ears? 
Do  you  ever  come  to  school  with  pieces  of  cotton  in  your 
ears?  "  In  this  group  there  are  no  children  who  complain  of 
running  ears.  Ordinarily  we  find  about  four  per  cent. 

"How  many  children  often  have  toothache?  "  Seventeen 
children  complain  of  more  or  less  toothache.  It  is  well  to 
remember  that  a  sound  tooth  never  aches,  although  it  is  also 
true  that  some  decayed  teeth  do  not  ache.  So  you  can  be 
sure  that  every  child  who  has  aching  teeth  has  unsound  teeth, 
but  you  cannot  be  sure  that  every  child  who  does  not  com- 
plain of  aching  teeth  has  sound  teeth. 

"How  many  children  here  have  a  toothbrush  at  home?  " 
Thirty-six  of  the  eighty-five  present  reply  that  they  have. 

"How  many  use  your  toothbrush  every  day?"  Only  seven 
reply  that  they  do.  Unless  a  child  uses  his  toothbrush  regu- 
larly you  may  be  perfectly  sure  that  he  does  n't  use  it  much, 
if  any.  It  is  one  thing  to  have  a  toothbrush,  but  quite  an- 
other thing  to  use  it,  and  particularly  to  use  it  correctly. 


102        HEALTH  WORK  IN  THE  SCHOOLS 

"  How  many  of  you  have  a  toothbrush  that  is  all  your  own, 
that  nobody  else  uses?  "  The  answer  indicates  that  there  are 
about  three  "common  "  toothbrushes.  This  is  a  smaller  pro- 
portion than  we  usually  find.  We  generally  discover  about 
five  to  ten  in  every  hundred  children  who  use  the  "family  " 
toothbrush. 

"How  many  children  always  have  the  bedroom  window 
open  at  night,  even  in  cold  weather?"  Sixty-five  of  the 
eighty-five  present  do  not  have  ventilated  bedrooms  when 
the  weather  is  cold. 

How  many  children  have  ever  been  to  a  dentist?  "  Only 
twenty-eight  out  of  eighty-five  have  been  to  a  dentist  at 
some  time.  The  rest  apparently  have  never  been  at  all. 

"How  many  of  you  children  drink  coffee?"  Sixty-eight 
reply  that  they  do.  The  proportion  is  usually  about  seventy- 
five  per  cent. 

"How  many  of  you  always  eat  some  fruit  for  breakfast?  " 
Eighteen  out  of  eighty-five  respond  that  they  do.  The  re- 
mainder apparently  do  not,  and  yet  fruit  in  some  form  is  a 
most  important  article  of  diet  for  the  child. 

"How  many  children  here  always  have  some  meat  or  some 
eggs  to  eat  for  breakfast?  "  About  four  fifths  of  the  children 
are  standing.  Usually  we  discover  that  over  half  of  the  chil- 
dren eat  starchy  breakfasts  of  a  most  inadequate  nature. 

Physiological  and  chronological  age 

At  this  point  I  would  like  to  call  your  attention  to  the  fact 
that  we  have  in  the  schools  a  very  considerable  number  of 
pupils  in  whom  there  is  a  great  discrepancy  between  the 
physiological  and  chronological  age.  Under-developed  chil- 
dren are  often  immature  in  mental  as  well  as  physical  make- 
up, and  for  this  reason  they  are  prone  to  exhaustion  and 
early  neurasthenia  when  subjected  to  the  same  school  strains 
which  stronger  and  more  mature  children  of  the  same  actual 
age  can  easily  withstand.  Teachers  and  parents  should  give 
careful  attention  to  the  physiologically  immature  child,  for 
they  may  in  many  instances  save  such  from  serious  conse- 
quences in  later  life. 

Please  observe  the  group  of  pupils  now  standing  before  you. 
There  are  five  children,  all  eleven  years  of  age,  but  physio- 


A  DEMONSTRATION  CLINIC  103 

logically  there  are  apparently  great  differences  present. 
Between  the  largest  and  the  smallest  child  here  there  is  a 
difference  of  over  forty  pounds  in  weight  and  eight  inches  in 
height,  to  say  nothing  of  differences  in  muscular  strength, 
lung  capacity,  general  endurance,  etc.  These  children  are 
all  expected  to  do  exactly  the  same  school  work,  but  it  is 
evident  from  the  most  superficial  examination  that  some  of 
them  are  relatively  weak  and  immature.  The  smallest  child 
in  this  group  has  to  my  personal  knowledge  a  definite  neuro- 
sis at  this  very  moment. 

Summary  of  the  observations 

Now,  to  make  a  rapid  summary  of  what  we  have  discov- 
ered here,  by  a  few  very  simple  questions :  We  note  that  of 
85  pupils,  16  apparently  have  definite  defects  of  vision;  5 
have  chronic  earache;  none  complain  of  running  ears;  8  have 
chronic  headache;  17  have  frequent  toothache;  57  have  never 
been  to  a  dentist;  only  38  have  toothbrushes  of  their  own, 
and  of  these  but  7  use  them  every  day;  there  are  3  "com- 
mon," or  "family"  toothbrushes;  65  have  unventilated bed- 
rooms in  cold  weather;  67  have  no  fruit  for  breakfast;  about 
one  fifth  have  no  proteid  food  for  breakfast;  and  68  drink 
coffee. 

In  addition  to  the  points  which  have  been  brought  out  in 
this  demonstration  clinic  to-day  it  is  easy  for  the  teacher  to 
make  observations  in  respect  to  the  following  conditions :  — 

Frequent  sore  throat. 

Malnutrition. 

Nervous  disorders. 

Deformities. 

Defective  postures. 

Glandular  enlargements  in  the  neck. 

Goitre. 

Skin  diseases. 

Early  contagious  disorders. 

Hygiene  teaching 

[At  this  point  the  children  were  dismissed  and  the  rest  of 
the  talk  was  addressed  to  the  teachers.] 


104        HEALTH  WORK  IN  THE  SCHOOLS 

This  little  questionnaire  not  only  brings  out  the  existence 
of  a  very  considerable  number  of  physical  handicaps,  but 
ought  to  aid  you  very  materially  in  discovering  what  sort  of 
hygiene  teaching  is  most  needed  with  a  given  room  of  pupils, 
and  I  would  recommend  it  to  you  particularly  for  this  pur- 
pose. It  is  of  no  particular  use  to  teach  children  about  things 
which  are s  not  related  to  their  daily  lives,  but  by  such  a 
series  of  questions  you  can  find  out  almost  exactly  what 
things  they  most  need  to  know  in  respect  to  their  personal 
health.  If  a  child  suffers  from  earache,  or  if  several  children 
suffer  from  earache,  the  rest  of  the  group  in  the  room  will  be 
interested  and  some  teaching  on  the  subject  of  earache  will 
be  effective.  The  same  may  be  said  of  toothache,  visual  de- 
fects, and  the  other  things  which  we  have  mentioned. 

Notifying  'parents 

A  word  now  about  how  to  get  a  response  from  the  parent, 
after  the  teacher  has  discovered  that  physical  defects  are 
present.  A  blank  notice  ought  to  be  used,  such  as  is  found  in 
the  little  survey  which  the  Minnesota  State  Board  of  Health 
furnishes  free  to  teachers.    The  notice  reads  as  follows: 

'* appears  to  the  teacher  to  be  in  need  of 

attention.  A  further  examination  by  your  family  physician, 
dentist,  or  specialist,  is  advised."  Now,  you  see  that  the 
notice  simply  says  "appears  to,"  and  consequently  does  not 
definitely  commit  the  teacher.  This  notice  is  signed  by  the 
Principal  of  the  school,  or  by  the  Superintendent.  The 
teacher  simply  writes  in  whatever  she  thinks  is  wrong  with 
the  pupil.  In  the  majority  of  instances  you  will  find  that  the 
notice  receives  no  attention  whatever  on  the  part  of  the  par- 
ent, and  this  is  one  great  difficulty  that  teachers  complain 
about  in  respect  to  this  health  work  that  they  are  asked  to 
carry  on.  Parents  seem  to  be  quite  indifferent  to  the  physical 
handicaps  of  their  children.  However,  this  is  only  an  appar- 
ent indifference.  The  real  difficulty  is  that  the  parent  does 
not  understand  the  significance  of  the  conditions  found  in 
the  child.  A  parent  does  not  appreciate  that  adenoids  have 
serious  consequences.  He  does  not  know  that  there  is  any 
relation  between  aching  and  discharging  ears  and  adenoids, 
or  between  adenoids  and  crooked,  prominent  teeth  and  reced- 


A  DEMONSTRATION  CLINIC  105 

ing  chin,  or  between  adenoids  and  catarrh,  or  between  en- 
larged, diseased  tonsils  and  rheumatism,  or  between  visual 
defects  and  headache  and  nervousness,  and  so  on  indefinitely. 
Now  what  the  parent  really  needs  is  some  simple  information 
along  these  lines.  When  once  he  really  understands  the  situ- 
ation, in  almost  every  case  he  will  cooperate.  I  have  found 
this  to  be  the  case  by  long  experience  in  work  with  school 
children.  In  order  to  give  the  parent  the  kind  of  instruction 
which  he  requires,  I  think  the  best  plan  is  to  send  with  the 
notice  which  the  child  takes  home  a  little  pamphlet  which 
describes  in  very  simple  language  what  the  defect  is,  and 
what  the  consequences  of  such  a  defect  are  when  neglected. 

Mentally  peculiar  and  defective  children 

Exceptional  children  of  various  types  have  been  in  our 
schools  since  schools  began,  but  only  within  the  past  few 
years  has  any  systematic  attempt  been  made  to  recognize 
and  classify  them.  Indeed,  such  recognition  and  classifica- 
tion was  almost  impossible  until  psychologists  developed 
practical,  direct  methods  for  the  use  of  schools.  Teachers 
have  always  been  able  to  point  out  some  "fools"  in  their 
classes,  and  other  types  of  exceptional  children  have  been 
vaguely  recognized,  but  "fools"  have  been  present  who  were 
thought  to  be  merely  slow  or  dull;  "misfits"  who  were  sup- 
posed to  be  "fools";  dullards  who  were  considered  "mis- 
fits"; and  so  on  indefinitely.  It  remained  for  the  psycholo- 
gists to  devise  methods  whereby  these  various  types  might 
be  studied  and  classified,  and  among  these  must  be  particu- 
larly mentioned  Witmer  and  Goddard  of  this  country,  and 
Binet  in  France. 

In  1905  Binet  and  Simon,  of  Paris,  first  published  their 
tests,  now  popularly  known  as  the  "Binet  Scale,"  and  in  1908 
and  1911  they  still  further  developed  and  improved  this 
method.  These  tests  have  from  time  to  time  been  modified, 
enlarged,  and  improved  by  various  other  psychologists, 
including  among  others  Goddard  of  Vineland,  Kuhlmann  of 
Faribault,  and  Terman  of  Stanford. 

The  Binet  method  still  leaves  much  to  be  desired,  but  is 
nevertheless  serving  to  stimulate  teachers  as  they  have  never 
been  stimulated  before  to  make  careful  observations  of  the 


106        HEALTH  WORK  IN  THE  SCHOOLS 

unusual  types  of  children  under  their  care.  According  to 
recent  investigations,  and  especially  those  of  Goddard,  from 
1  to  3  per  cent  of  the  children  in  our  public  schools  are 
mentally  defective,  and  this  in  spite  of  the  fact  that  they 
are  frequently  unrecognized  as  such  by  either  their  parents 
or  teachers.  Such  children  often  present  no  physical  signs  of 
such  defectiveness  and  may  indeed  be  among  the  best- 
looking  children  in  a  grade.  Sooner  or  later,  however,  chil- 
dren of  this  type  become  retarded,  and  attention  is  thus 
called  to  them.  A  safe  rule  for  teachers  to  follow  is  that 
every  child  who  is  retarded  in  school  two  or  more  years  with- 
out evident  reason  should  be  suspected  of  possessing  some 
degree  of  mental  defectiveness.  Not  every  child  who  is  thus 
retarded  is  feeble-minded,  but  proof  to  the  contrary  should 
at  least  be  established  before  the  child  is  removed  from  sus- 
picion. Degrees  of  feeble-mindedness  are  present  among 
school  children,  varying  all  the  way  from  low  grade  imbecil- 
ity to  the  condition  of  the  high-grade  feeble-minded  person 
known  as  the  "moron,"  who  is  just  below  the  line  of  nor- 
mality. 

For  example,  I  recently  examined  a  girl  of  fourteen  who 
had  been  in  the  first  grade  for  five  successive  years,  and  it 
soon  became  apparent  that  she  had  a  mentality  of  about 
three  years.  Beyond  this  degree  of  intelligence  there  is  no 
reason  to  believe  she  will  ever  pass.  Another  child  had  a 
chronological  or  actual  age  of  fourteen  and  a  mental  age  of 
eight  and  one  half.  This  boy  may  perhaps  develop  to  a  men- 
tal age  of  a  normal  child  of  nine  or  ten  years,  but  not  much 
beyond  this.  Still  another  pupil  had  an  actual  age  of  sixteen 
with  a  mental  age  of  only  nine.  Another  was  twelve  years 
old  with  a  mental  age  of  seven.  In  every  one  of  these  cases 
the  teacher  knew,  of  course,  that  something  was  wrong,  for 
all  were  retarded  in  school,  but  that  it  was  true  feeble- 
mindedness was  never  suspected  except  in  the  first  instance, 
and  even  here  it  was  not  understood  by  parent  or  teacher 
that  the  child  was  practically  non-educable.  On  the  other 
hand,  a  boy  of  fourteen  was  considered  feeble-minded  by  his 
teacher  when  he  was  only  a  misfit. 

Every  village  and  city  school  system  which  I  have  visited 
has  produced  cases  of  retarded,  feeble-minded  children,  and 
where  there  was  time  to  make  any  sort  of  adequate  study  of 


B  fl 

Hi          f 

* 

^ 

it 

CHRONOLOGICAL  AND   PHYSIOLOGICAL  AGE 
These  five  children  are  all  eleven  years  old. 


A  DEMONSTRATION  CLINIC  107 

the  question  the  proportion  has  appeared  to  be  just  about 
that  estimated  by  Goddard,  viz.,  2  per  cent. 

The  following  types  of  exceptional  children  require  careful 
attention  on  the  part  of  teachers:  (1)  Retarded  children 
(especially  those  retarded  two  or  more  years) ;  (2)  slow  chil- 
dren (not  necessarily  retarded);  (3)  precocious  children 
(especially  those  who  are  delicate);  (4)  delinquent  children; 
(5)  misfit  children;  (6)  highly  nervous  children. 

In  order  to  decide  whether  a  child  is  actually  deficient  in 
mentality,  some  competent  teacher  in  every  school  system 
should  familiarize  herself  with  the  Binet  method  for  measur- 
ing the  intelligence  of  children.  Such  a  teacher  need  not  be 
expected  to  become  an  expert  or  to  obtain  very  exact  results, 
but  she  may  at  least  in  the  majority  of  cases  arrive  at  a  con- 
clusion which  will  establish  the  fact  of  f eeble-mindedness  or 
normality.  The  exact  degree  of  feeble-mindedness  present  in 
a  child  is  a  matter  for  a  clinical  psychologist  or  school  medi- 
cal officer  to  determine,  but  this,  though  desirable  is  not 
always  indispensable  knowledge  in  the  practical  classifica- 
tion of  school  children. 

[Eight  retarded  children  were  now  called  into  the  room 
and  arranged  in  a  line,  with  a  ninth  standing  in  front  of  them. 
It  was  recommended  that  in  each  case  the  actual  mental 
age  ought  to  be  determined  by  the  Binet  scale.  These  chil- 
dren gave  their  ages  and  grades  as  follows :  — 


1 

13  years 

5th  grade 

2 

12 

<« 

4th  " 

3 

13 

" 

4th  " 

4 

13 

<« 

5th  " 

5 

13 

<< 

5th  " 

6 

13 

« 

5th  " 

7 

12 

M 

4th  " 

8 

14 

" 

5th  " 

9 

9 

" 

2d   " 

A  subsequent  examination  proved  that  only  two  of  these 
children  had  a  mental  age  equal  to  their  actual  age.] 

Children  who  are  merely  dull  will  not  and  cannot  receive  a 
great  deal  of  education,  but  their  judgment  is  usually  not 
bad.  We  should  not  try  to  educate  these  pupils  too  much. 
They  will  succeed  fairly  well  in  the  world  along  lines  not 


108        HEALTH  WORK  IN  THE  SCHOOLS 

requiring  superior  intelligence.  The  mentally  defective  child, 
on  the  other  hand,  has  defective  judgment  as  well  as  defec- 
tive intelligence.  He  does  not  profit  by  the  ordinary  kind  of 
school  education  at  all.  Either  the  school  must  provide 
special  lines  of  work  for  him,  or  else  he  must  be  sent  to  an 
institution  for  defectives.  Children  nine  years  of  age  or  less 
who  are  mentally  retarded  as  much  as  two  years,  and  chil- 
dren from  nine  to  thirteen  who  are  retarded  as  much  as 
three  years,  do  not  ordinarily  belong  in  the  public  schools. 
They  should  be  kept  in  state  institutions  for  the  feeble- 
minded. Few  who  are  retarded  this  amount  can  be  made 
self-supporting. 

A  word  of  caution  is  required.  Do  not  depend  upon  the 
Binet  or  any  other  method  exclusively.  Use  common  sense. 
Do  not  disregard  ordinary  school  methods  of  judgment.  Do 
not  regard  the  Binet  Scale  as  one  which  can  be  used  with  the 
absolute  certainty  of  a  measuring  stick.  Make  use  of  any  and 
all  methods  available  in  the  estimation  of  the  intelligence  of 
exceptional  children.  Finally,  regard  your  conclusions  in 
most  instances  as  tentative,  and  carefully  watch  the  develop- 
ment of  each  case. 

The  other  types  of  children  mentioned,  viz.,  the  dull,  pre- 
cocious, nervous,  and  misfit,  require  as  careful  study  as  the 
feeble-minded.  Indeed,  they  deserve  perhaps  more  atten- 
tion, because  these  are  the  types  which  under  proper  disci- 
pline make  satisfactory  progress  and  may  be  saved  years  of 
unnecessary  sorrow  and  ineffective  effort. 

Professor  Terman's  handbook  for  the  study  of  excep- 
tional children,  containing  the  most  accurate  revision  of  the 
Binet  Scale  which  has  yet  been  made,  will  be  issued  about 
January,  1915.  It  will  give  special  attention  to  the  simplifi- 
cation of  the  directions  for  applying  the  Binet  method  so 
that  it  may  be  used  by  any  teacher. 


IC 
£TE] 


Date  .    Lrfi  1( 

Grades  J  &  4 

Number  1 55 

-I 

No  ventij  x 

Own  a  tc  57 

Daily  usi  22 

Use  of  cq  x 

Never  li£j  x 

Frequenl(i7 

Frequent^ 

Blurred  1  7 

Frequentj  e 

Running  3 

Frequent}  q 

Adenoids)  3 

Diseased   4 

No  form  ng 

No  fruit  ^0 

Daily  useB3 

of  cc 


CHAPTER  VII 

THE  SCHOOL  MEDICAL  CLINIC 

Difficulty  of  getting  results  from  medical  inspection 

Dr.  H.  H.  Hogarth,  assistant  medical  officer  of 
Education  for  the  London  County  Council,  has  made 
an  observation  in  his  excellent  book  on  the  Medical 
Inspection  of  Schools  to  the  truth  of  which  all  experi- 
enced school  doctors  will  assent.  "Every  school  doc- 
tor," he  says,  "goes  through  the  same  process  of 
reflection  and  education.  At  first  he  enters  the  school 
as  a  novice,  recognizing  that  his  duty  is  to  inspect,  not 
to  treat;  that  his  own  position  is  open  to  attack  on  the 
part  of  his  brother  practitioners;  that  he  may  be  inter- 
fering with  the  rightful  responsibilities  of  parents.  He 
is  so  absorbed  in  the  new  work,  the  new  ideas;  so  inter- 
ested in  the  children,  the  educational  system,  and  the 
teachers,  that  as  soon  as  he  has  notified  parent  and 
teacher  that  a  child  is  suffering  from  some  particular 
disease,  leaving  them  to  take  whatever  further  action 
may  be  necessary,  he  considers  he  has  done  his  part. 
It  is  not  until  he  returns  a  year  later  that  he  realizes 
how  completely  his  advice  has  been  ignored.  Then  he 
begins  to  think" 

As  has  already  been  emphasized,  medical  inspection 
in  the  beginning  was  little  more  than  inspection.  The 
early  New  York  inspectors  found  that  ninety-four  per 


110        HEALTH  WORK  IN  THE  SCHOOLS 

cent  of  their  notifications  failed  to  bring  results.  In 
England,  likewise,  where  poverty  is  more  widespread 
than  with  us,  the  results  were  so  disappointing  as  to 
awaken  everybody  concerned  to  a  realization  of  the 
futility  of  any  system  of  inspection  which  takes  no 
steps  to  ameliorate  the  evils  it  discovers. 

Casting  about  for  means  to  accomplish  this  end, 
school  authorities  have  discovered  a  number  of  reme- 
dies of  various  degrees  of  effectiveness.  One  of  these 
is  the  system  of  school  nurses,  already  discussed.  An- 
other remedy,  supplementary  to  school  nursing,  and 
of  even  greater  portent  for  preventive  medicine,  is  the 
school  clinic. 

What  the  school  clinic  is 

The  school  clinic  is  a  clinic  controlled  by  the  educa- 
tional authorities,  and  supported  at  public  expense  for 
the  purpose  of  permitting  a  more  thorough  examina- 
tion, and  in  some  cases  also  treatment,  of  defects  re- 
vealed by  the  routine  inspection.  In  many  cities  the 
work  of  the  clinic  is  confined  to  the  first  of  these  func- 
tions. The  school  doctor  on  his  rounds  finds  children 
whose  condition  merits  a  more  thorough  diagnosis  than 
can  be  given  in  the  preliminary  and  rather  superficial 
survey.  The  parents  of  such  children  are  asked  to 
bring  them  to  the  clinic  for  special  examination  and 
advice.  If  grave  defectiveness  or  disease  is  found,  the 
parents  are  urged  to  secure  the  necessary  treatment 
from  the  family  physician,  or  in  case  of  extreme  pov- 
erty the  school  doctor  may  arrange  with  local  hospitals 


THE  SCHOOL  MEDICAL  CLINIC  111 

or  dispensaries  for  gratuitous  service.  Clinics  for  this 
diagnostic  and  advisory  purpose  have  everywhere 
rapidly  followed  the  introduction  of  medical  inspec- 
tion. In  cities  above  15,000  or  20,000  population  they 
are  fast  coming  to  be  looked  upon  as  a  standard  re- 
quirement of  any  system  of  school  medical  service. 

The  main  purpose  of  this  chapter,  however,  is  to 
describe  a  somewhat  different  type  of  school  clinic, 
already  becoming  numerous  in  England  and  not  un- 
known in  the  United  States,  —  a  clinic  designed  to 
afford  more  or  less  treatment  as  well  as  diagnosis. 

Typical  school  medical  clinics  of  England 

Dr.  Lewis  Williams'  account 1  of  the  school  clinic  at 
Bradford,  England,  gives  an  excellent  idea  of  the  sig- 
nificance of  this  new  medico-educational  institution. 
Bradford  is  a  manufacturing  city  of  about  300,000 
population.  The  school  clinic  was  opened  about  two 
years  ago,  in  the  hope  that  it  would  make  possible  the 
treatment  and  cure  of  that  large  percentage  of  children 
who,  because  of  indigence  or  parental  neglect,  had 
received  no  benefit  from  the  inspection  of  their  defects. 
The  staff  consists  of  three  physicians,  one  dentist,  two 
nurses,  and  two  clerks,  all  on  full  time.  Treatment  is 
free,  except  that  parents,  when  able,  are  required  to 
pay  the  actual  cost  of  eye-glasses.  Although  attend- 
ance is  voluntary,  objection  to  treatment  is  very  sel- 
dom met  with.  The  reason  for  this  lies  partly  in  the 
absence  of  expense,  but  perhaps  still  more  in  the  psy- 
1  See  reference  5,  at  the  end  of  this  chapter. 


112        HEALTH  WORK  IN  THE  SCHOOLS 

chological  difference  between  persuading  parents  to  do 
something  and  merely  securing  their  consent  to  have 
it  done.  The  former  violates  the  principle  of  human 
inertia;  the  latter  takes  advantage  of  it.  The  following 
table  shows  what  the  Bradford  clinic  accomplished  in 
1910:  — 

Number  treated 

Defective  vision 650 

External  eye  disease 576 

-r,.  (  of  head 623 

Ringworm  jofbody m 

Verminous  heads 360 

Scabies  and  impetigo 419 

Ear  discharge 285 

Defective  teeth 450 

Stammering 150 

Infectious  disease 1052 

Of  the  5000  who  secured  free  treatment  at  the  clinic, 
certainly  very  few  would  have  received  any  other  atten- 
tion whatever.  Ringworm  of  the  head  was  treated  by 
the  X-ray  method,  one  exposure  being  sufficient  in  over 
92  per  cent  of  the  cases.  At  a  cost  of  from  30  to  65 
cents  each,  559  pairs  of  glasses  were  supplied.  A  spe- 
cial teacher  was  employed  to  give  breathing  exercises 
and  other  treatment  to  stammering  children. 

In  1908,  a  clinic  was  opened  in  the  Poplar  School, 
London,  organized  by  Miss  Margaret  MacMillan  and 
endowed  by  Mr.  Joseph  Fels.  This  is  interesting  as 
showing  what  can  be  accomplished  by  a  small  clinic, 
drawing  its  cases  from  only  about  1000  children  of  a 
single  school.1  During  the  two  years  from  December 
1  See  article  by  Dr.  Tribe,  in  School  Hygiene  for  May  1911. 


THE  SCHOOL  MEDICAL  CLINIC  113 

1908  to  December,  1910,  450  pupils  came  under  treat- 
ment in  this  clinic,  or  nearly  half  the  total  enrollment 
of  the  school.  An  analysis  of  210  of  the  450  cases  shows 
a  number  of  interesting  facts.  Twenty-three  cases 
were  treated  daily  for  ear  discharge,  until  cured.  On 
the  average,  the  number  of  months  required  to  cure  a 
discharging  ear  about  equaled  the  number  of  months 
the  ear  had  been  neglected.  The  clinic  recommended 
35  cases  of  adenoids  or  enlarged  tonsils  for  operation, 
and  out  of  this  number  met  only  two  refusals.  Fifty- 
five  children  were  treated  for  anaemia  or  debility,  of 
whom  32  were  either  cured  or  distinctly  improved.  Of 
the  210  cases  analyzed,  cure  was  effected  for  94,  21 
were  improved,  67  were  still  under  treatment  when  the 
report  was  made,  8  had  been  transferred  to  a  hospital, 
and  9  had  left  school.  All  of  this  was  accomplished 
with  no  interference  in  attendance,  and  at  slight  ex- 
pense. 

Similar  school  clinics  have  been  established  in  Eng- 
land in  many  other  cities. 

Cost,  equipment  and  management 

Hogarth  estimates  that  $7500  will  usually  suffice  to 
build  and  equip  a  clinic  for  a  city  of  20,000  population, 
counting  $2500  for  equipment  and  $5000  for  building. 
It  should  provide  five  or  six  rooms,  as  follows:  One 
large  and  one  small  waiting-room,  two  consulting- 
rooms  (for  physician  and  dentist),  a  dark  room,  and  a 
nurse's  room.  For  a  large  staff  more  room  will  be  re- 
quired. The  staff  should  include  an  oculist,  a  general 


114       HEALTH  WORK  IN  THE  SCHOOLS 

physician,  a  dentist,  nurses,  and  assistants.  In  small 
cities  the  staff  is  usually  composed  of  regular  practicing 
physicians,  who  receive  official  appointments  to  devote 
from  one  to  three  half -days  per  week  to  the  work.  The 
customary  remuneration  is  about  $5  for  each  half- 
day  of  work.  Some  of  the  larger  clinics,  like  that  of 
Bradford,  employ  all  the  physicians  on  full  time.  Dr. 
Williams  thinks  full-time  employment  preferable,  wher- 
ever it  is  feasible.  The  physicians  become  more  inter- 
ested in  their  work,  and  come  to  see  more  clearly  its 
educational  bearings.  Another  practical  advantage  of 
this  plan  is  that  it  is  less  likely  to  create  friction  between 
the  school  physician  and  local  practitioners.  When  the 
school  physician  also  engages  in  practice  he  is  likely 
to  be  suspected  of  using  his  office  to  secure  patronage 
for  himself. 

Why  free  clinics  are  necessary 

The  policy  of  free  medical  and  dental  clinics  sup- 
ported by  public  taxation  differs  in  no  respect  from 
the  universally  accepted  principle  of  public  education. 
The  latter,  in  effect,  presupposes  the  former,  inasmuch 
as  children  with  neglected  physical  defects  cannot  re- 
ceive in  full  the  benefits  which  the  school  has  to  offer. 
It  would  be  folly  to  permit  any  a  priori  social  theory  to 
blind  us  to  the  essential  facts. 

At  the  risk  of  repetition  let  us  review  some  of  the 
obstacles  encountered  in  the  process  of  education  and 
of  medical  inspection  which  have  led  to  such  an  unfore- 
seen and  radical  departure  from  our  ancient  moorings. 


THE  SCHOOL  MEDICAL  CLINIC  115 

The  most  important  and  common  defects  and  dis- 
eases revealed  by  medical  inspection  are  defective  vis- 
ion, discharging  ears,  adenoids  and  hypertrophied  ton- 
sils, tuberculosis,  enlarged  glands,  carious  teeth,  and 
malnutrition.  The  purpose  of  medical  inspection  being 
to  combat  racial  degeneracy  and  to  conserve  vitality, 
its  sole  justification  lies  in  the  contribution  it  makes  to 
this  end.  This  may  sound  trite,  but  it  is  fundamental. 
The  following  are  illustrations  of  the  difficulties  met  in 
the  accomplishment  of  this  purpose. 

Discharging  ears,  as  has  been  shown,  present  a  con- 
dition of  great  seriousness,  and  need  in  most  cases  to 
have  daily  attention,  such  as  syringing,  washing,  etc. 
Now  experience  proves  that  usually  parents  will  not, 
even  when  urgently  and  repeatedly  advised  by  the 
school  doctor  or  nurse,  secure  for  the  child  so  afflicted 
the  proper  medical  care.  As  a  rule  they  lack  the  knowl- 
edge of  hygiene  and  medicine  which  would  enable  them 
to  appreciate  the  situation.  Others,  and  these  are  very 
numerous,  canot  afford  the  services  of  expert  oculists 
or  aurists  at  current  rates,  and  are  reluctant  to  accept 
as  charity  what  they  have  not  the  means  to  command. 
Even  when  the  aurist  is  consulted  for  a  discharging 
ear,  the  tedious  treatment  which  ensues,  often  lasting 
many  months,  is  seldom  carried  out  by  parents  with 
the  needed  regularity  and  carefulness.  Physicians  find 
that  in  most  cases  it  is  simply  folly  to  expect  a  cure  by 
this  method.  The  only  assurance  of  success  in  this 
direction  is  for  the  child  to  be  taken  daily  to  the  physi- 
cian's office  or  to  the  hospital  for  the  necessary  treat- 


116        HEALTH  WORK  IN  THE  SCHOOLS 

ment.  Aside  from  the  question  of  expense  or  the  preju- 
dice against  charity,  it  is  useless  to  expect  that  this  will 
be  done.  Each  visit  may  consume  from  two  to  four 
hours  of  time.  Whether  rich  or  poor  we  are  too  busy 
and  impatient  to  submit  to  such  a  tedious  ordeal.  The 
result  is  that  nine  tenths  of  the  cases  of  ear  discharge 
among  school  children  have  been  neglected.  Theorize 
as  we  may  about  the  danger  of  tampering  with  parental 
responsibility  by  the  support  of  school  clinics  for  free 
treatment,  we  are  confronted  by  this  fact  of  neglect. 

With  the  inauguration  of  the  school  clinic  the  entire 
problem  vanishes.  The  child  goes  daily  to  the  near-by 
clinic,  often  in  the  building  where  he  attends  school, 
and  receives  the  necessary  treatment  at  the  hands  of 
nurse  or  doctor.  There  is  no  waste  of  time,  no  loss  of 
school  attendance,  and  a  mere  bagatelle  of  expense. 
Best  of  all,  the  treatment  brings  cure. 

Most  of  the  other  forms  of  defectiveness  offer, 
with  greater  or  less  variation,  the  same  problems  and 
the  same  solution.  In  the  case  of  defective  vision,  for 
example,  to  secure  parental  action  requires,  in  about 
50  per  cent  of  the  cases,  from  two  to  four  home  visits 
by  the  school  nurse.  In  the  case  of  15  to  30  per  cent, 
nothing  is  ever  accomplished.  Many  who  respond  do  so 
by  seeking  the  inexpert  advice  of  opticians.  Now  and 
then  a  parent  buys  a  pair  of  ten-cent  goggles  from  a 
street  peddler  and  thinks  that  in  this  sacrifice  he  has 
paid  due  homage  to  Hygeia.  A  small  minority  take 
their  children  to  a  reputable  oculist  and  have  them  cor- 
rectly fitted  with  glasses,  at  an  expense  of  $5  to  $30 


THE  SCHOOL  MEDICAL  CLINIC  117 

each.  Only  a  very  small  minority,  be  it  said  to  the 
credit  of  humanity,  seek  for  or  permit  assistance 
through  laws  for  relief  of  the  poor.  The  sum  total  of 
results  is  disappointing,  notwithstanding  the  cost  in 
time  and  energy.  Upon  the  establishment  of  the 
school  clinic  of  the  English  type  the  situation  is  com- 
pletely changed.  When  a  child  is  discovered  with  de- 
fective vision,  instead  of  hounding  the  parents  with 
arguments  and  pleadings,  the  child  is  sent  to  the  clinic 
and  is  tested  for  glasses.  The  clinic  even  secures  for 
the  child  necessary  lenses  and  frames  at  special  rates, 
arranged  for  by  the  school  authorities  with  a  reliable 
optician.  The  cost  ranges  from  30  to  60  cents,  and  is 
met  by  the  parents,  if  they  are  able;  if  not,  by  the 
school  board.  In  English  cities,  such  as  Bradford, 
about  80  per  cent  are  paid  for  by  the  parents.  But  the 
important  points  are  that  the  eyes  actually  receive 
treatment,  that  the  treatment  is  skillful,  and  that  the 
cost  is  inconsiderable. 

In  like  manner,  enlarged  glands,  tuberculous  ten- 
dencies, throat  occlusions,  and  many  other  defects  re- 
quire either  more  expert  or  more  constant  attention 
than  they  are  likely  to  receive  from  the  family  doctor. 
The  X-ray  treatment  for  ringworm  is  a  good  illustra- 
tion of  the  efficiency  that  may  be  secured  by  the  intro- 
duction of  wholesale  methods  into  medical  practice. 
Only  a  few  practitioners  have  the  equipment  for  treat- 
ment; those  who  have  it  charge  high  fees,  while  the 
disease  is  common  only  among  the  poor.  Left  to  such  a 
combination  of  circumstances  the  disease  would  flour- 


118        HEALTH  WORK  IN  THE  SCHOOLS 

ish  indefinitely.  The  properly  equipped  school  clinic 
practically  eradicates  it  from  a  middle-sized  city  within 
a  few  months,  and  at  an  expense  which  is  almost  neg- 
ligible. 

By  the  old  way  everything  had  to  be  done  with  a 
maximum  of  inconvenience,  resistance,  and  leakage. 
The  chief  obstacle  always  was  human  inertia,  the  most 
characteristic  trait  of  mankind.  If  the  success  of  any 
cause  is  contingent  upon  a  general  abandonment  of  the 
way  of  least  resistance,  that  cause  is  already  lost.  An 
issue  may  have  the  passive  favor  of  all  the  people  and 
yet  fail  of  fruitage  through  neglect.  The  old  system 
tried  to  persuade  the  parents  to  do  something;  the 
school  clinic  only  asks  their  assent.  The  school  clinic 
attains  the  desired  results  and  does  it  without  friction. 

The  opposition  to  free  school  clinics 

The  opposition  comes  chiefly  from  practising  physi- 
cians, some  of  whom  look  with  apprehension  upon 
every  social  movement  which  seems  to  point  toward 
an  ultimate  socialization  of  their  profession.  The  issue, 
however,  becomes  clear  if  we  only  remember  that  dis- 
ease is  to  be  conceived  as  an  evil  to  be  eradicated,  not 
as  a  resource  to  be  conserved  for  the  benefit  of  any 
profession.  Partly  by  his  own  fault,  and  partly  for 
social  and  economic  reasons,  the  family  doctor  has 
failed  to  keep  the  people  well.  The  family  doctor  insti- 
tution need  not  be  abolished,  but  it  must  be  supple- 
mented. What  it  has  not  done  at  all,  or  what  it  has 
done  only  with  huge  waste  of  effort,  presents  a  legiti- 


THE  SCHOOL  MEDICAL  CLINIC  119 

mate  field  for  organized  social  endeavors.  There  is  no 
likelihood  that  any  considerable  portion  of  physicians 
will  oppose  the  general  introduction  of  the  school 
clinic,  though  organizations  like  the  League  for  Med- 
ical Freedom  may  be  expected  to  do  so  most  vigor- 
ously. 

A  committee  of  physicians  commissioned  by  the 
local  medical  association  to  inquire  into  the  bearing  of 
the  Bradford  clinic  upon  private  medical  practice 
reported  as  follows:  "Your  committee  consider  that 
the  school  clinic  as  carried  on  at  Bradford  has  not 
hitherto  proved  detrimental  to  the  interests  of  practi- 
tioners of  that  district."  l  What  the  school  clinic  ac- 
complishes is  pure  gain. 

To  protect  the  health  of  children  is  a  social  obligation 
It  is  hardly  necessary,  interesting  as  it  would  be,  to 
speculate  upon  the  final  outcome  of  the  school  clinic. 
Whether  it  will  lead  to  the  complete  socialization  of 
medicine  and  dentistry,  just  as  education  has  been 
socialized,  is  a  question  it  is  impossible  to  answer.  It  is 
certain,  however,  that  social  regulation  and  control 
over  matters  pertaining  to  the  health  of  children  will 
be  extended  in  the  future  rather  than  limited.  Intrin- 
sically there  is  nothing  more  radical  in  the  principle  of 
free  medical  and  dental  treatment  than  in  the  Ameri- 
can scheme  of  public  education  and  free  textbooks. 
From  the  beginning  the  cry  about  weakening  parental 

1  Quoted  by  Dr.  Lewis  Williams  in  his  article  on  "  School  Clinics, " 
in  School  Hygiene  for  March,  1911. 


120        HEALTH  WORK  IN  THE  SCHOOLS 

responsibility  has  been  raised  against  both.  Gradually 
we  are  learning  that  it  is  less  a  question  of  parental 
responsibility  than  of  children's  rights.  Private  enter- 
prise has  done  too  little  for  the  health  of  our  children  to 
justify  any  claim  to  a  monopoly  of  the  business.  It 
matters  little  what  social  procedure  we  adopt  to  insure 
that  our  children  grow  as  nearly  as  may  be  into  their 
full  heritage  of  health  and  strength,  as  long  as  the  end 
is  accomplished.  Least  of  all  need  we  prematurely  be 
frightened  by  the  specter  of  socialism.  To  protect  the 
bodies  of  children  from  defective  development  is  not  a 
question  of  socialism,  but  of  humanity  and  of  common 
sense. 

The  school  clinic  is  effective  from  the  mere  fact  that 
it  is  an  integral  part  of  the  educational  machinery.  It 
works  in  the  closest  relations  with  teachers,  attendance 
officers,  and  nurses.  The  presumption  is  all  in  favor  of 
the  child.  His  case  will  be  watched  from  day  to  day. 
The  more  it  comes  under  the  observation  of  the  school 
physician,  the  greater  is  the  probability  that  needed 
modifications  of  the  curriculum  will  be  made.  In  the 
words  of  Dr.  Lewis  Williams,  "inasmuch  as  those  very 
diseases  which  chiefly  affect  school  children  and  play 
such  havoc  with  school  efficiency  and  school  attend- 
ance are  the  very  ones  most  neglected  by  parents  in 
spite  of  medical  inspection,  the  school  clinic  plainly 
becomes  the  only  method  of  dealing  with  the  diffi- 
culty." As  forcibly  stated  by  Hogarth,  "to  secure  an 
improved  physical  condition  for  the  next  generation,  to 
obtain  a  higher  standard  both  of  school  attendance 


THE   SCHOOL  MEDICAL  CLINIC  121 

and  of  education,  to  give  a  fair  chance  to  thousands 
who  are  now  hopelessly  handicapped  before  the  race  is 
well  begun,  are  aims  which  cannot  be  lightly  set  aside." 

Summary 

We  may  summarize  the  benefits  of  the  school  clinic 
as  follows :  — 

(1)  It  gives  opportunity  for  a  more  thorough  exam- 
ination of  serious  or  puzzling  cases  than  is  possible  in 
the  ordinary  routine  of  medical  inspection.  This  bene- 
fit is  derived  from  all  school  clinics  and  has  no  neces- 
sary connection  with  any  scheme  of  free  treatment. 

(2)  It  is  the  function  of  the  school  clinic  to  render 
the  final  decision  in  regard  to  segregations  in  open-air 
schools,  special  classes  for  the  deaf  and  dumb,  or 
schools  for  mentally  defective  children. 

(3)  The  bacteriological  department  of  the  school 
clinic  regulates  authoritatively  and  conveniently 
exclusions  for  contagious  disease,  and  readmissions 
upon  recovery.  A  certificate  of  freedom  from  contag- 
ion issued  by  the  practising  physician  is  often  worth- 
less. The  latter  may  have  neither  the  bacteriological 
training  nor  the  laboratory  equipment  to  enable  him 
to  make  scientific  determinations  of  the  presence  or 
absence  of  pathogenic  bacteria.  Hogarth  found  that 
out  of  240  certificates,  issued  by  Bradford  physicians, 
of  freedom  from  scabies  (itch),  234  were  incorrect. 

(4)  The  school  clinic  alone  is  in  position  to  maintain 
the  close  relations  with  the  school  and  with  the  indi- 
vidual pupils  which  will  insure  the  constant  attention 


122        HEALTH  WORK  IN  THE  SCHOOLS 

necessary  to  the  successful  treatment  of  chronic  de- 
fects. This  is  especially  true  of  discharging  ears,  mal- 
nutrition, tuberculosis,  etc. 

(5)  In  all  lines  of  defectiveness  the  English  type  of 
school  clinic  brings  results  which  it  has  not  been  pos- 
sible to  secure  by  any  other  means.  Through  its  work, 
eye  defects  are  corrected,  discharging  ears  are  cured, 
adenoids  are  removed,  teeth  are  repaired,  verminous 
conditions  are  eradicated.  The  logical  issue  of  diagno- 
sis is  adequate  and  skillful  treatment.  This  is  what  the 
school  clinic  insures. 

(6)  The  introduction  of  systematic  and  wholesale 
methods  in  preventive  medicine,  and  the  consequent 
saving  of  time,  energy,  and  equipment,  puts  the  whole 
matter  upon  a  different  economic  basis.  Adenoid  oper- 
ations, eyeglasses,  X-ray  treatment  of  ringworm,  and 
the  like,  are  reduced  to  a  small  fraction  of  their  former 
cost.  Vaccinations  by  the  school  physician  at  the  rate 
of  twenty-five  cents  per  child  are  just  as  effective  as 
when  performed  by  the  practitioner  for  two  dollars.1 

(7)  The  school  clinic  should  not  be  conducted  as  a 
semi-charitable  institution.  The  practice  of  restricting 
treatment  to  such  cases  as  have  been  investigated  and 
recommended  by  local  charity  organizations  is  inde- 
fensible. To  make  a  certificate  of  indigency  the  badge 
of  admission  is  to  brand  those  who  accept  its  benefits 

1  Under  the  recent  state  law  of  compulsory  vaccination  at  private 
expense  Californians  have  been  compelled  to  expend  annually  for 
vaccinations  alone  an  amount  of  money  large  enough  to  support  an 
efficient  system  of  medical  inspection  for  half  the  schools  of  the 
State. 


THE  SCHOOL  MEDICAL  CLINIC  123 

with  the  stigma  of  pauperism.  In  protecting  the  lives 
and  fostering  the  health  of  children  it  must  be  remem- 
bered that  we  are  not  conferring  a  charity,  but  per- 
forming a  duty. 

(8)  All  the  stock  arguments  against  the  operation  of 
school  clinics  prove  on  examination  to  be  untenable. 
To  oppose  the  principle  on  which  the  institution  rests 
is  to  deny  the  right  and  duty  of  society  to  engage  in 
organized  effort  to  conserve  the  raw  material  of  the 
coming  State. 

(9)  The  school  clinic  affords  to  the  school  doctor 
much-needed  relief  from  the  monotony  of  routine 
inspection.  The  importance  of  this  point  cannot  easily 
be  overestimated.  Experience  proves  that  after  the 
novelty  has  worn  off  the  work  of  inspection,  the  physi- 
cian is  almost  sure  to  become  restless  and  discontented. 
He  feels  that  he  is  not  making  any  professional  growth, 
as,  indeed,  is  too  likely  to  be  true,  considering  the  limi- 
tations and  restrictions  of  his  duties.  Permission  to 
give  treatment  both  broadens  his  professional  outlook 
and  satisfies  a  legitimate  and  natural  desire  to  accom- 
plish objective  results. 

(10)  The  school  clinic  should  be  enlarged  to  include 
a  psychological  branch,  in  addition  to  the  medical  and 
dental  work. 

REFERENCES 

*1.  Crowley,  Dr.  R.  H.:  The  Hygiene  of  School  Life.  1910,  pp.  167- 

83. 
2.  Elder,  Dr.  M.:  "The  Deptford  School  Clinic."  School  Hygiene, 

1911,  pp.  580-88. 
*3.  Terman,  Lewis  M.:  "School  Clinics,  Dental  and  Medical." 

The  Psychological  Clinic,  1912,  pp.  271-78. 


; 


124        HEALTH  WORK  IN  THE  SCHOOLS 

4.  Tribe,  Dr.  R.:  "Results  of  Treatment  at  the  Poplar  School 

Clinic  (London.")   School  Hygiene,  May,  1911. 
*5.  Williams,  Dr.  Lewis:  "School  Clinics."   In  Kelynack's  Medical 

Inspection  of  Schools  and  Scholars,  1910,  chapter  xm,  pp.  218- 

31. 
6.  Williams,  Dr.  Lewis:  "School  Clinics."  School  Hygiene,  March, 

1911. 


CHAPTER  VIII 


SCHOOL  DENTISTRY 


Historical 

School  dentistry  had  its  beginning  in  Strassburg, 
Germany,  in  1902.  The  undertaking  was  due  entirely 
to  the  enthusiastic  efforts  of  Dr.  Ernst  Jessen,  whose 
name  therefore  deserves  an  honored  place  in  the  his- 
tory of  school  hygiene.  The  Strassburg  clinic  is  sup- 
ported at  public  expense,  and  is  open  without  charge 
to  the  school  children  of  the  city,  rich  and  poor.  Al- 
though attendance  upon  the  clinic  is  entirely  volun- 
tary, the  patronage  has  been  very  gratifying,  as  the 
following  table  will  show. 

TABLE  III 


No.  treated 

No.  available 
for  treatment 

Total  cost. 

1st  year 

2d      " 

3d      " 

4th    " 

2666 
4967 
6828 
7491 

17,119 
17,054 
18,073 
18,607 

$1355.00 
1685.00 
2135.00 
2250.00 

At  first,  more  than  half  of  those  who  offered  them- 
selves for  treatment  were  impelled  by  toothache,  but 
the  number  coming  for  other  purposes  rapidly  in- 
creased. A  pupil  seldom  refuses  to  attend,  when  urged 
by  the  teacher. 

Results  were  evident  from  the  beginning.  After  the 
repair  of  their  teeth  many  children  improved  in  health, 


126        HEALTH  WORK  IN  THE  SCHOOLS 

absence  from  school  noticeably  decreased,  and  in 
some  cases  discipline  became  easier.  In  Strassburg  the 
clinic  has  the  loyal  support  of  the  teachers,  medical  in- 
spectors, and  a  large  majority  of  the  parents.  One  of  its 
most  valuable  results  is  the  influence  it  exerts  as  a  con- 
stant object  lesson  in  hygiene  to  both  pupil  and  parent. 

Before  long  the  school  authorities  at  Strassburg  were 
overwhelmed  with  inquiries  from  every  part  of  the 
world.  By  1907,  thirty-three  cities  and  towns  in  Ger- 
many had  instituted  school  dental  clinics,  and  by  1909 
the  number  was  about  fifty.  They  are  now  quite  gen- 
eral in  the  larger  cities,  and  traveling  clinics  for  rural 
schools  are  coming  to  be  popular. 

In  the  smaller  cities  there  are  usually  two  or  three 
school  dentists,  working  on  part-time.  Wiesbaden, 
with  8000  school  children,  has  six.  Other  cities,  taking 
Strassburg  for  their  model,  employ  full-time  dentists, 
and  admit  them  to  pension  rights  on  the  same  footing 
as  teachers. 

The  cost  for  salaries,  materials,  and  up-keep  of  clinics 
is  sometimes  met  entirely  by  public  taxation,  and 
sometimes  in  part  by  private  philanthropy;  but  in 
either  case  the  treatment  is  free  to  the  pupil.  The  per 
capita  expense  in  Germany  is  ridiculously  small.  As 
shown  by  the  above  table,  the  cost  in  Strassburg  is  less 
than  twenty-five  cents  a  year  for  each  child  treated. 
Of  forty-nine  cities  reporting  in  1909,  the  cost  per 
child  was  greater  than  this  in  only  four.1 

1  Other  cities  in  Germany,  such  as  Mannheim,  Stuttgart,  etc., 
prefer  to  send  the  child  to  a  private  dentist  of  his  own  choice  and  to 


SCHOOL  DENTISTRY  127 

In  England,  school  dentistry  has  had  a  rapid  devel- 
opment, though  the  sentiment  there  is  less  favorable 
to  the  free  treatment  of  children  whose  parents  can 
afford  to  pay.  The  Cambridge  Dental  Institute  for 
Children,  one  of  the  best  known  of  England's  school 
clinics,  was  organized  in  1907  at  private  expense,  and 
was  taken  over  after  two  years  by  the  Borough  Coun- 
cil. Before  the  work  began  in  1908,  the  average  num- 
ber of  unfilled  carious  teeth  per  Cambridge  child  was 
1,  2,  3,  and  4  for  the  ages  6,  7,  8,  and  9  respectively. 
After  three  years  the  number  had  fallen  to  .3,  .6,  1.5, 
and  1.6  for  the  same  ages.  In  1908,  24  per  cent  of  the 
children  accepted  treatment;  in  1909,  25  per  cent;  and 
in  1910,  39  per  cent.  By  this  time  72  per  cent  of  the 
children  had  sound,  or  artificially  sound,  teeth;  before 
the  work  began,  only  33  per  cent.  Of  those  urged  to 
take  treatment  the  first  year,  and  refusing,  40  per  cent 
accepted  treatment  later.1  The  greatest  problem  in 
Cambridge  has  been  to  get  parents  to  bring  the  chil- 
dren, even  though  the  treatment  is  absolutely  free. 
Experience  in  other  English  cities  proves  that  even  a 
nominal  charge  dooms  the  school  dental  clinic  to  failure. 
One  point  in  the  Cambridge  plan  deserves  special 
mention;  namely,  the  concentration  of  effort  upon  the 
younger  children.  When  the  funds  available  are  inade- 
quate to  the  task  of  putting  in  order  the  teeth  of  all  the 
children,  the  Cambridge  plan  insures  the  greatest  good 

pay  the  expense  of  the  dental  work  done,  rather  than  to  employ  a 
school  dentist.  Of  course  it  matters  little  who  does  the  work  so  long 
as  it  is  really  done. 

1  See  Wallis,  School  Dental  Clinics.   (Reference  6.) 


128        HEALTH  WORK  IN  THE  SCHOOLS 

to  the  greatest  number.  The  average  cost  of  keeping  a 
child's  teeth  in  repair  throughout  its  school  life,  begin- 
ning with  the  first  year,  is  probably  less  than  the  aver- 
age cost  of  one  treatment  for  the  older  child  whose 
teeth  have  been  neglected,  and  the  good  accomplished 
is  proportionately  greater.  When  this  is  done  with 
every  entering  class  the  total  expense  involved  is  not 
large,  and  the  teeth  may  thereafter  be  easily  kept  in 
satisfactory  condition  with  but  slight  annual  repairs.1 
In  the  United  States,  dental  clinics  have  been  estab- 
lished in  New  York,  Chicago,  Philadelphia,  Cleveland, 
Los  Angeles,  and  in  nearly  all  of  the  other  large  cities. 
Many  of  the  smaller  cities  are  following  the  example. 
Boston  is  fortunate  in  the  establishment  of  the  For- 
syth Dental  Infirmary,  made  possible  by  the  generos- 
ity of  John  Hamilton  and  Thomas  Forsyth.  The  insti- 
tution is  housed  in  a  magnificent  building  and  is  en- 
dowed with  $1,000,000  for  maintenance.  The  gift  is 
entirely  for  the  benefit  of  Boston  children  under  the 
age  of  sixteen  years.  Practical  instruction  in  mouth 
hygiene  is  given,  a  dental  museum  is  supported,  and  a 
room  is  available  for  public  lectures.  The  institution 
also  supports  a  research  fellowship  for  the  investiga- 
tion of  dental  diseases. 

Dental  clinics  should  be  free 

For  the  most  part,  the  school  clinic  in  the  United 
States  is  conducted  for  the  benefit  of  indigent,  or  semi- 

1  The  same  plan  is  being  followed  in  West  Newton,  Massachu- 
setts. 


SCHOOL  DENTISTRY  129 

indigent,  children.  It  is  frankly  a  charitable  institu- 
tion, belonging  in  the  same  category  as  orphanages, 
poorhouses,  etc.  It  is  also  different  in  that  much  of  the 
dental  service  is  rendered  gratuitously  by  local  dental 
associations.  In  those  cases  where  the  dentist  receives 
pay  for  his  school  work  the  expense  is  usually  borne  by 
charitable  organizations,  and  not  by  the  school. 

The  objections  urged  against  the  public  support  of 
free  dental  clinics  are  the  same  as  those  urged  against 
school  feeding,  and  precisely  the  same  as  those  urged  a 
few  generations  ago  against  free  public  schools:  namely, 
that  the  people  would  be  pauperized,  that  parental 
responsibility  would  be  lessened,  and  that  the  income 
of  private  practitioners  would  be  jeopardized.  Experi- 
ence proves  that  the  first  two  objections  are  ground- 
less. Parental  responsibility  is  created  rather  than 
destroyed,  and  pauperization  is  no  more  caused  by 
free  school  dentistry  than  by  free  textbooks  and  tui- 
tion. It  is  not  even  probable  that  the  income  of  private 
dentists  would  be  sensibly  affected.  The  universal 
care  of  children's  teeth  in  the  schools  would  soon  make 
the  dentist  habit  universal,  so  that  in  a  few  years  all 
persons  beyond  school  age  would  be  patrons  of  the 
private  dentist,  instead  of  the  present  10  or  15  per  cent. 
Moreover,  many  of  the  wealthier  classes  who  now  pa- 
tronize private  dentists  for  their  children  would  con- 
tinue to  do  so,  even  if  free  school  clinics  were  estab- 
lished. The  larger  part  of  the  work  which  is  done  by 
the  free  dental  clinic  would  otherwise  not  be  done  at 
all.  The  good  it  accomplishes  is  clear  gain. 


130        HEALTH  WORK  IN  THE  SCHOOLS 

Anyway,  it  is  the  welfare  of  the  child  which  is  sought, 
ot  the  aggrandizement  of  a  profession.]  By  the  whole- 
sale methods  used  in  the  schools,  the  cost  of  dentistry 
is  reduced  to  about  one  third  of  what  it  would  amount 
to  if  done  by  private  dentists.  There  is  no  reason  why 
society  should  neglect  the  teeth  of  children  in  the  inter- 
ests of  private  dentists,  any  more  than  it  should  yield 
up  their  bodies  in  the  interest  of  the  private  manufac- 
turer who  fattens  on  child  labor. 

We  seem,  indeed,  to  be  on  the  eve  of  a  great  dental 
crusade,  —  a  crusade  which  promises  to  make  the 
public-school  dentist  as  familiar  a  personage  as  the 
superintendent  himself,  and  fully  as  indispensable. 
There  is  no  alternative  to  the  German  method. 

In  order  to  expedite  his  work,  the  school  dentist 
stands  in  need  of  an  assistant,  just  as  the  school  doctor 
must  have  his  nurses.  Laws  need  to  be  enacted  legal- 
izing the  profession  of  the  school  dental  nurse.  The 
dental  nurse,  on  proper  certification,  by  examination 
or  otherwise,  would  be  permitted  to  examine  teeth  in 
the  schools,  clean  them,  and  apply  local  treatment  to 
allay  pain.  A  large  share  of  the  school  dentist's  time 
would  thus  be  saved. 


Preventing  dental  decay 

At  least  80  per  cent  of  the  children  in  our  schools  have 
seriously  defective  teeth.  In  the  upper  grades,  to  be  sure, 
many  of  these  dental  disabilities  have  been  repaired. 
But  a  repaired  tooth,  after  all,  is  only  a  makeshift.  It  is 
always  in  danger  of  a  functional  or  organic  breakdown. 


Orthodontia  restores  the  jaw  to  normal  shape. 


w 

.. 

1           *           jl 

"^^HB^nJi 

'^%M 

Teeth  like  these  can  be  made  straight. 
CROOKED   TEETH 


SCHOOL  DENTISTRY  131 

Modern  dentistry  is  preventive  in  nature,  and 
teaches  that  teeth  need  not  necessarily  decay  at  all. 
With  a  few  exceptions,  such  as  those  found  in  certain 
cases  of  general  faulty  development,  or  conditions  re- 
sulting from  acute  diseases,!  teeth  may  be  kept  from 
decay  by  the  simple  device  of  keeping  them  clean. ) 

The  toothbrush  cannot  be  relied  on  for  this  purpose. 
Not  over  twenty  children  out  of  a  hundred  use  a  tooth- 
brush with  needed  regularity,  and  hardly  any  of  these 
know  how  to  use  it  correctly.  Most  of  them  brush  with 
a  crosswise  stroke  instead  of  with  an  up-and-down 
motion.  Even  when  correctly  used  the  brush  does  not 
insure  that  every  part  of  the  tooth  surface,  inner  as 
well  as  outer,  will  be  kept  clean.  The  latest  and  best 
method  of  insuring  complete  cleanliness,  and  thus 
guarding  against  decay  is  as  follows:  — 

As  soon  as  the  child  has  cut  his  first  set  of  teeth,  an 
attempt  is  made  to  remove  placque  formation  as  rap- 
idly as  it  occurs.  Placques  are  deposits  in  and  under 
which  acid-forming  bacteria  find  lodgment.  Decay  of 
teeth  is  due  primarily  to  those  bacteria  of  the  mouth 
which  produce  lactic  acid.  This  decay  takes  place 
under  the  placques.  Consequently  prompt  removal  of 
this  deposit  insures  the  teeth  against  decay.  To  detect 
the  placques,  which  are  often  invisible  to  the  eye  or 
even  the  touch,  the  teeth  are  swabbed  with  a  "disclos- 
ing solution"  made  of  the  tincture  of  iodine  and  a  little 
glycerine.  After  the  teeth  are  washed  with  water,  the 
solution  leaves  the  placques  stained  brown,  while  the 
rest  of  the  tooth  remains  white.  The  brown  spots  or 


132         HEALTH  WORK  IN  THE  SCHOOLS 

placques  are  now  rubbed  with  a  moist  silica  prepara- 
tion, and  dental  ribbon  which  is  treated  with  the  same 
material  is  run  between  the  teeth. 

This  procedure  repeated  about  twice  a  month  keeps 
the  teeth  relatively  free  from  placques.  It  is  necessary, 
however,  to  visit  the  dentist  at  least  every  six  months 
for  a  more  thorough  treatment  than  can  be  given  by 
the  parent  at  home.  This  method  followed  conscien- 
tiously will  prevent  decay,  give  the  enamel  a  beautiful 
luster  and  save  at  least  seventy-five  per  cent  of  the 
usual  expense  for  dental  repairs. 

At  best,  dental  repair  is  a  purely  mechanical  process 
which  gives  evidence  to  the  world  of  previous  dental 
neglect.  In  only  a  restricted  sense  is  it  a  hygienic  mea- 
sure. The  method  just  described,  combined  with  the 
proper  care  of  the  gums  and  surface  of  the  tongue,  as- 
sures a  degree  of  oral  cleanliness  which  defies  the  as- 
saults of  the  bacteria  of  the  mouth. 

REFERENCES  " 

1.  Jessen,  Dr.  Ernst:  Die  Zahnpflege  in  der  Schule  vom  Standpunkt 
des  Aerztes.   1909,  pp.  67. 

2.  Jessen,  Dr.  Ernst:  " Schulzahnpflege  u.  Schule."  Proc.  2nd  Inter. 
Cong.  Sch.  Hyg.,  1907,  pp.  495-502. 

3.  Jessen,  Dr.  Ernst:  "Kostenpunkt  einer  StUdtischen  Schulzahn- 
klinik."   Inter.  Mag.  Sch.  Hyg.,  vol.  iv,  1908,  pp.  432-36. 

4.  Jessen,  Dr.  Ernst :    Die  Zahnarztliche  Behandlung  der  Volkschul- 
kinder."   Inter.  Mag.  Sch.  Hyg.,  1907,  pp.  205-22. 

5.  Schlegel,  Dr.:  "The  Reading  (Pa.)  Free  Dental  Dispensary." 
Psych.  Clinic,  February,  1910. 

A  •       6.  Wallis,  C.  E.:  School  Dental  Clinics:  Their  Foundation  and  Man- 
agement. London,  1913. 
.      7.  Wimmenauer,  Dr.:  "Schularzte  u.  Schulzahnhygiene. "     Zt  f. 
Schulges.,  1911,  pp.  882-93. 

1  On  problems  relating  to  the  growth  and  care  of  children's  teef  h 
see  Lewis  M.  Terman's,  The  Hygiene  of  the  School  Child,  chapter  xi. 
Houghton  Mifflin  Co.,  1914. 


CHAPTER  IX 

TRANSMISSIBLE  DISEASES 

The  mortality  in  the  United  States  from  measles, 
scarlet  fever,  whooping-cough,  and  diphtheria  amounts 
every  year  to  more  than  twice  the  loss  of  life  on  the 
field  of  Gettysburg.  On  the  basis  of  the  knowledge 
which  we  now  have  regarding  the  causes  of  these  dis- 
eases and  the  modes  of  their  transmission,  probably 
more  than  half  of  this  loss  should  be  looked  upon  as 
absolutely  preventable.  The  annual  needless  mortal- 
ity from  this  cause,  therefore,  exceeds  the  slaughter  in 
most  of  the  bloodiest  battles  of  the  world's  history. 
Thousands  of  other  deaths  result  from  complications 
following  children's  transmissible  diseases. 

The  school  as  a  factor  in  the  spread  of  contagious  diseases 

For  some  of  this  loss  the  school  is  directly  respon- 
sible, particularly  in  the  case  of  measles  and  diphtheria. 
Statistics  collected  from  many  parts  of  the  world  have 
established  this  beyond  doubt.  When  society  forcibly 
brings  children  together  in  the  public  school  it  is  mor- 
ally responsible  for  the  sickness  and  deaths  which 
result  from  such  compulsory  contact. 

Thus  Korosi  found  that  for  a  large  number  of  Ger- 
man cities,  taken  together,  the  average  number  of 
cases  of  measles  per  month,  over  a  period  of  eighteen 


134        HEALTH  WORK  IN  THE  SCHOOLS 


years,  was  less  than  one  sixth  as  great  during  vacation 
as  for  the  school  months.  Dr.  Schaefer  found  similar 
differences  for  Hamburg,  though  the  vacation  decrease 
for  scarlet  fever  and  diphtheria  was  much  less  marked 
than  for  measles.  In  Chicago,  for  the  two  years  1899 
and  1900,  the  average  monthly  frequency  of  both  scar- 
let fever  and  diphtheria  was  more  than  twice  as  great 
during  the  school  months  as  in  vacation. 

The  following  curve  shows  the  average  monthly 
mortality  from  measles  in  the  city  of  London  for  the 


Jan.  Bleb.  Mar.  Apr.  May.  Jun.  Jul.  Aug.  Sep.  Oct.  Nov.  Dec. 

60 
63 
50 
45 
40 
35 
30 
25 
20 
15 
10 
5 

A 

M 

/ 

t 

\ 

/ 

\ 

i 

f 

\ 

\ 

\ 

1 

\ 

J 

FIG.  3 

Weekly  average  of  deaths  from  measles  in  London,  England,  summed  up  for 
ten  years,  1900-1910.    See  influence  of  vacation.    (Fairfield.) 


5 


II 


1 

1 

a 
*  3 

WS 

*$ 

i 

"3 


^ 


136        HEALTH  WORK  IN  THE  SCHOOLS 

years  1900  to  1910,  averaged  together.  Attention  is 
called  to  the  marked  influence  of  even  the  short  vaca- 
tion there  given. 

Fig.  4  shows  a  similar  influence  of  the  school  on  the 
prevalence  of  diphtheria  in  Halle,  Germany,  for  the 
years  1906  to  1912  taken  together. 

The  school  as  a  means  of  controlling  contagious 
diseases 

However,  in  spite  of  the  dangers  which  the  school 
involves  for  the  spread  of  contagious  diseases,  it  affords 
at  the  same  time  unexcelled  opportunity  for  their  con- 
trol and  prevention.  Everywhere  the  medical  super- 
vision of  schools  has  accomplished  much  in  this  way. 
In  the  year  1906-07  medical  inspectors  discovered  the 
following  cases  of  contagious  diseases  in  the  public 
schools  of  Massachusetts :  — 

TABLE  IV 

Diphtheria 238 

Scarlet  fever 313 

Measles 637 

Whooping-cough 973 

Mumps 367 

Chickenpox 548 

Influenza 276 

Syphilis 36 

Tuberculosis 115 

Scabies  (itch) 1054 

Pediculosis  (head  lice) 7691 

Impetigo 1568 

Conjunctivitis 779 

Ringworm 715 

Other  skin  diseases,  mostly  contagious 1170 


TRANSMISSIBLE  DISEASES  137 

These  cases  were  all  discovered  among  children 
present  at  school,  and  their  immediate  exclusion  must 
have  prevented  a  vast  number  of  infections  otherwise 
inevitable. 

Since  medical  inspection  was  instituted  in  Boston, 
diphtheria  in  that  city  has  decreased  65  per  cent  and 
scarlet  fever  75  per  cent,  and  both  are  now  less  com- 
mon in  school  months  than  during  vacation.  In  other 
words,  by  vigilance  the  school  department  of  hygiene 
can  more  than  offset  the  increased  danger  of  epidemics 
incident  to  school  attendance.  When  we  remember 
that  90  per  cent  of  all  deaths  from  these  diseases  occur 
before  the  age  of  10  years,  the  importance  of  their 
prompt  and  efficient  control  through  the  school  ma- 
chinery readily  becomes  apparent. 

Our  ideas  on  the  transmissible  diseases  of  children 
are  rapidly  changing.  Instead  of  waiting  for  these  dis- 
eases to  make  their  appearance,  we  now  attempt  to  dis- 
cover those  conditions  which  favor  them,  in  order  that 
we  may  remove  the  soil  most  favorable  to  their  growth 
and  dissemination. 

"Newer  ideas  about  modes  of  infection 

Recent  studies  of  the  contagious  diseases  of  child- 
hood have  brought  about  a  radical  change  in  our  view- 
point in  regard  to  their  modes  of  infection.  In  the  past 
it  was  the  custom  of  both  school  people  and  medical 
officers  to  concentrate  their  attention  upon  the  various 
objects  (fomites)  which  had  been  in  rather  close  con- 
tact with  the  sick  person,  as  the  probable  sources  of 


138        HEALTH  WORK  IN  THE  SCHOOLS 

infection.  Within  the  meaning  of  this  term  were  in- 
cluded a  great  many  articles,  such  as  bedding,  books, 
toys,  clothing,  furniture,  letters,  desks,  pencils,  money, 
etc. 

At  present  the  best  informed  medical  men  are  paying 
less  attention  to  fomite  infection,  and  more  to  infection 
through  personal  contact.  In  other  words,  attention  is 
now  being  fixed  on  persons  rather  than  things  as  the 
sources  of  infection.  Modern  bacteriological  investiga- 
tions have  pretty  conclusively  demonstrated  that  in  the 
majority  of  instances  diseases  are  spread  directly  from 
one  individual  to  another,  rather  than  through  an 
intermediate  object  of  some  sort.  With  the  old  theory 
of  fomite  infection,  a  great  amount  of  time,  energy, 
and  money  was  expended  on  methods  of  disinfection, 
all  to  very  little  purpose.  To-day  far  more  efficient 
results  are  obtained  by  discovering,  isolating,  and  con- 
trolling the  individual  carrier  of  the  disease.  Trans- 
missible diseases  are,  of  course,  transmitted  only  by 
means  of  living,  active,  micro-organisms  of  some  sort. 
We  are  fast  learning  that  these  living  organisms,  or 
germs,  which  are  either  plant  or  animal  in  nature, 
cannot  ordinarily  live  long  outside  of  their  particu- 
lar host.  For  this  reason  we  believe  less  to-day  than 
formerly  in  dust  infection,  air  infection,  book  infection, 
infection  through  clothing  and  the  like. 

Danger  of  the  common  cup,  common  towel,  etc. 

Contact  infection  is  undoubtedly  the  commonest 
and  by  far  the  most  certain  mode  of  infection.   But 


TRANSMISSIBLE  DISEASES  139 

contact  infection  does  not  exclude  infection  by  means 
of  various  objects  which  may  carry  fresh  material  from 
the  infected  individual.  Thus,  diphtheria  germs  may 
easily  be  carried  from  the  mouth  of  a  sick  child  to  the 
mouth  of  a  well  one  by  means  of  a  pencil,  provided  the 
pencil  has  very  recently  been  in  the  mouth  of  the  child 
ill  with  diphtheria.  Similarly  a  handkerchief  used  in 
common  by  a  well  child  and  one  sick  with  measles 
easily  carries  the  infection  to  the  well  child. 

What  is  said  in  this  connection  is  not  to  be  construed 
as  a  vindication  of  the  common  drinking-cup,  which  is 
always  dangerous.  Davison,  who  made  bacteriological 
examinations  of  a  large  number  of  public  drinking-cups, 
found  that  nearly  all  harbored  dangerous  germs,  and 
that  37.5  per  cent  bore  the  tubercule  bacilli.  Bensel's 
experiment  of  allowing  diphtheria  patients  to  drink 
once  from  a  glass  sterilized  for  the  purpose  demon- 
strated that  germs  of  the  disease  were  deposited  in  from 
25  to  40  per  cent  of  the  cases.  Measles,  scarlet  fever, 
whooping-cough,  tuberculosis,  and  syphilis  are  known 
to  be  transmitted  frequently  in  this  way.  The  common 
drinking-cup  in  public  places  has  been  legislated  out  of 
existence  in  more  than  a  dozen  States  since  Kansas  set 
the  example  in  1909.  By  1911,  more  than  forty  rail- 
roads in  the  United  States  had  substituted  individual 
cups.1 

The  common  cup  and  the  common  towel  will  both 
have  to  go.    The  best  substitute  for  the  former  is  a 

1  Common  drinking-cups  on  inter-state  trains  were  prohibited  by 
federal  regulation  in  1912. 


140        HEALTH  WORK  IN  THE  SCHOOLS 

rightly  constructed  drinking-fountain,  of  which  several 
are  on  the  market.  Individual  cups  are  usually  not 
kept  clean,  and  are  too  often  "borrowed."  The  com- 
mon towel  should  be  replaced  by  absorbent  paper  tow- 
els, which  are  used  once  and  then  discarded. 

It  has  been  shown  also  that  books  are  capable  of 
transmitting  diseases,  though  the  likelihood  of  their 
doing  so  has  probably  been  exaggerated.  At  any  rate, 
guinea-pigs  have  been  inoculated  with  tuberculosis  and 
other  diseases  by  preparations  made  from  library 
books.  The  danger  from  this  source  is  probably  suffi- 
cient to  justify  city  boards  of  health  in  making  daily 
reports  on  contagious  diseases  to  public  libraries,  and 
books  known  to  have  been  recently  used  by  infected 
persons  should  be  disinfected  by  the  moist,  hot  air 
method.  This  requires  exposure  of  the  books  for  about 
thirty-two  hours  in  an  atmosphere  of  80°  C.  (176°  F.) 
and  30  to  40  per  cent  humidity.  The  method  is  said  not 
to  be  injurious  to  the  most  delicate  book. 

The  modes  of  transmission  just  mentioned  are  in 
reality  to  be  classed  with  contact  infections.  What  is 
meant,  then,  by  contact  infection  is  contact  with  the 
virile  specific  germ  of  the  disease,  either  directly 
through  the  patient  or  indirectly  by  means  of  an  object 
which  carries  fresh  material  from  the  patient.  It  is  not 
denied  that  infection  by  air  or  by  fomites  does  some- 
times occur,  but  the  evidence  to-day  is  all  against  these 
modes  in  the  great  majority  of  cases. 


TRANSMISSIBLE  DISEASES  141 

Air  not  a  common  source  of  infection 

It  is  not  unnatural  that  air  should  have  been  so  long 
considered  one  of  the  chief  vehicles  of  infection,  for  it 
has  been  relatively  few  years  since  the  germ  principle 
of  disease  was  discovered.  Chapin  says,  "Until  this 
germ  idea  was  well  established  as  a  fact,  the  infective 
material  was  supposed  to  emanate  from  the  surface 
of  the  body  and  from  moist  soil  and  decomposing 
matter  of  all  kinds.  Contagious  diseases  were  known 
to  arise  without  any  apparent  connection  with  other 
cases,  and  what  could  be  more  natural  than  to  assume 
that  the  invisible,  imponderable  materies  morbi  is  mixed 
with  and  carried  by  air?  "  Even  to-day  one  finds  some 
educated,  as  well  as  many  ignorant,  individuals  and 
some  entire  communities  believing  that  stagnant  pools 
of  water  breed  typhoid,  that  "sewer  gas"  may  give 
rise  to  diphtheria,  that  drafts  of  air  may  cause  pneu- 
monia, that  air  from  marshes  gives  rise  to  malaria,  etc. 
These  and  many  similar  delusions  persist,  despite  the 
fact  that  we  now  possess  abundant  evidence  to  the  con- 
trary. While  it  is  possible  that  air  may  at  times  carry 
the  germs  of  some  diseases,  it  is  now  acknowledged  by 
those  most  entitled  to  an  opinion  that  air  does  not 
often  carry  germs  in  a  condition  capable  of  producing 
infection.  That  diseases  are  often  spread  in  street- 
cars, trains,  churches,  schools,  theaters,  and  other 
crowded  places  is,  of  course,  a  matter  of  common 
knowledge  and  experience;  but  these  instances  are  sat- 
isfactorily explained  by  the  fact  that  a  large  number  of 


142        HEALTH  WORK  IN  THE  SCHOOLS 

individuals  are  here  associated  in  close  personal  con- 
tact. It  is  easy  under  such  conditions  for  infection  to 
spread  from  one  individual  to  another  by  means  of  the 
fine  spray  produced  by  coughing,  sneezing,  laughing, 
and  the  like. 

Isolation  of  "carriers**  versus  school  closing 

The  practical  abandonment  of  the  old  idea  of  f  omite 
and  air  infection,  except  in  rather  rare  and  exceptional 
instances,  has  resulted  in  an  entire  change  of  procedure 
in  respect  to  the  control  of  contagious  diseases  in 
schools.  The  time-honored  method  of  closing  and  dis- 
infecting a  school  during  an  epidemic  of  measles  or 
diphtheria  is  based  on  the  theory  of  fomite  and  air 
infection  in  the  school.  This  habit,  still  in  practice  in 
most  places,  results  in  loss  of  school  time  and  expense 
to  the  school  department.  Worse  still,  many  infected 
pupils  are  allowed  to  play  about  the  streets  among  well 
children,  and  thus  constantly  spread  the  infection. 
The  modern  practice,  which  gives  far  better  results,  is 
to  isolate  the  sick  children  and  those  believed  most 
likely  to  be  capable  of  carrying  infection,  while  the 
school  is  kept  in  operation. 

It  is  now  well  understood  that  individuals  who  are 
not  themselves  sick  may  often  carry  the  germs  of  cer- 
tain diseases  in  their  bodies.  This  is  true  of  diphtheria, 
typhoid  fever,  meningitis,  pneumonia,  influenza,  tuber- 
culosis, and  probably  of  scarlet  fever,  measles,  whoop- 
ing-cough, mumps,  and  some  other  diseases.  Such 
persons  as  carry  in  their  bodies  the  germs  of  a  dis- 


,. 


TRANSMISSIBLE  DISEASES  143 

ease  without  themselves  being  sick,  are  known  as 
"carriers.'* 

Dr.  Chapin  has  remarked  that  probably  the  most 
important  discovery  bearing  on  preventive  medicine, 
since  the  demonstration  of  the  bacterial  origin  of  dis- 
ease, is  that  disease  germs  frequently  invade  the  body 
without  causing  disease.  Where  the  throats  of  school 
children  have  been  examined  by  the  culture  method 
during  an  epidemic  of  diphtheria,  from  10  to  40  per 
cent  of  apparently  well  pupils  have  often  been  dis- 
covered who  were  carrying  diphtheria  bacilli  in  their 
throats,  and  were  quite  capable  of  giving  the  disease  to 
others.  In  an  epidemic  of  diphtheria  which  occurred  in 
Berkeley,  California,  in  1906,  Dr.  George  F.  Reinhardt 
found  25  per  cent  of  the  well  pupils  to  be  carriers. 
Prompt  isolation  of  both  the  sick  pupils  and  the  car- 
riers resulted  in  the  control  of  the  epidemic. 

Of  4526  contact  cases  among  wage-earners,  exam- 
ined in  Providence,  Rhode  Island,  during  a  diphtheria 
epidemic,  14.4  per  cent  were  found  to  have  the  diph- 
theria bacilli  present  in  their  throats.  It  was  signifi- 
cant in  this  instance  that  women  were  infected  much 
oftener  than  men;  the  explanation  being  that  women 
are  in  more  constant  and  intimate  contact  with  sick 
children  than  men  are. 

The  subject  of  contact  infection  cannot  be  dismissed 
without  reference  to  atypical  cases  of  transmissible 
diseases.  Formerly  it  was  supposed  that  most  if  not 
all  diseases  exhibited  definite,  characteristic  symp- 
toms, and  that  mild  atypical  cases  either  did  not  exist, 


144        HEALTH  WORK  IN  THE  SCHOOLS 

or  occurred  infrequently.  Now  we  know  that  many 
such  atypical  cases  occur,  and  that,  because  of  the 
fact  that  they  often  pass  unrecognized,  these  cases  are 
frequent  sources  of  epidemics.  Many  such  atypical 
cases  have  been  observed  in  diphtheria,  influenza,  scar- 
let fever,  smallpox,  and  typhoid  fever,  and  there  is  an 
evidence  of  such  cases  in  most  other  infectious  diseases. 

The  problem  to-day  is  as  much  one  of  discovering 
mild,  atypical  diseases  and  carriers  of  diseases  as  of 
locating  the  ordinary  cases.  With  the  recognition  of 
all  or  most  of  these  carriers  and  atypical  cases  the  con- 
trol of  epidemics  becomes  a  relatively  simple  matter. 
As  long  as  mild,  unrecognizable  cases  and  carriers  are 
allowed  to  go  about  freely,  no  possible  good  can  result 
from  the  closing  of  schools.  With  the  recognition  and 
isolation  of  these  cases,  the  closing  of  a  school  (with 
few  or  no  exceptions)  is  not  only  unnecessary  but  posi- 
tively undesirable  and  even  harmful,  for  the  unrecog- 
nized, mild,  atypical  cases  and  carriers  may  then  freely 
spread  disease  among  other  children. 

In  epidemics  of  infantile  paralysis,  epidemic  menin- 
gitis, and  possibly  a  few  other  diseases,  it  may  occas- 
ionally still  be  necessary  to  resort  to  the  closing  of 
schools,  but  if  this  procedure  is  unaccompanied  by 
isolation  of  the  exposed  as  well  as  the  sick  it  can  result 
in  little  good.  As  regards  smallpox  the  prompt  vaccin- 
ation of  all  unvaccinated  children  during  the  earliest 
days  of  an  epidemic  offers  so  perfect  a  protection  to  the 
well  that  closure  of  schools  becomes  an  entirely  unnec- 
essary and  even  harmful  procedure. 


TRANSMISSIBLE  DISEASES  145 

Ages  at  which  transmissible  diseases  most  often  occur 

It  is  most  important  for  schools  to  make  accurate 
collections  of  data  in  respect  to  transmissible  diseases, 
and  to  exhibit  this  so  far  as  possible  in  a  graphic  form 
by  means  of  charts  and  the  plotting  of  curves.  By  this 


FIG.  5 
Curve  indicating  average  seasonal  occurrence  of  all  children's  diseases  in  the 
Berkeley  Schools  for  the  years  1906-1910.    Note  that  the  curve  reaches  its 
height  in  March. 

method,  information  can  be  instantly  grasped  and  the 
problem  of  control  can  be  more  easily  solved.  The 
value  of  this  procedure  will  be  evident  from  the  follow- 
ing study,  made  in  the  schools  of  Berkeley,  Calif oraia.1 
A  simple  but  instructive  curve  plotted  from  the 
average  monthly  reports  of  all  transmissible  diseases 
in  Berkeley  from  1906  to  1910  shows  that  the  curve 

1  Hoag  and  Hall, "  A  Preliminary  Report  on  Contagious  Diseases 
in  Schools."   Bulletin,  American  Academy  of  Medicine,  1911. 


146        HEALTH  WORK  IN  THE  SCHOOLS 

reaches  its  maximum  in  March.  This  clearly  indicates, 
then,  that  March  is  the  sick  month  of  the  year  in  this 
community.  This  period  is  coincident  with  the  worst 
weather,  when  windows  at  home  and  at  school  are  kept 
closed  and  pupils  are  at  the  same  time  in  close  personal 
association  with  one  another  and  thus  offer  abundant 
opportunity  for  direct  infection  by  contact. 

Plotting  a  combined  age-curve  for  chickenpox,  diph- 
theria, mumps,  measles,  scarlet  fever,  whooping-cough, 
typhoid,  and  tuberculosis,  it  appeared  that  42  per  cent 
of  the  diseases  occur  between  the  ages  of  5  and  10 
years,  and  only  16  per  cent  between  the  ages  of  10  and 
15  years;  79  per  cent  occur  between  birth  and  15  years; 
only  13  per  cent  after  20  years.  In  other  words,  68  per 
cent  of  the  diseases  in  question  occur  in  children  of 
school  age.  Another  21  per  cent  occur  in  children  too 
young  to  attend  school. 

Of  the  reported  cases  of  measles,  28  per  cent  occur 
under  5  years;  48  per  cent  between  5  and  10  years;  13 
per  cent  between  10  and  15  years;  or  a  total  of  89  per 
cent  under  15  years. 

With  mumps,  only  6  per  cent  of  the  cases  oc- 
cur under  5  years;  but  50  per  cent  occur  between 
5  and  10  years,  and  26  per  cent  between  10  and  15 
years. 

In  chickenpox,  61  per  cent  occur  between  5  and  10 
years,  and  14  per  cent  under  five  years;  while  18  per 
cent  occur  between  10  and  15  years,  and  only  7  per 
cent  occur  after  15  years. 

In  scarlet  fever,  40  per  cent  occur  between  5  and  10 


TRANSMISSIBLE  DISEASES  147 

years,  28  per  cent  between  10  and  15  years,  and  15  per 
cent  under  5  years. 

Diphtheria  gives  23  per  cent  for  children  under  5 
years,  35  per  cent  from  5  to  10  years,  and  18  per  cent 
from  10  to  15  years,  the  cases  rapidly  diminishing  from 
this  age  on. 

In  whooping-cough  we  get  a  different  sort  of  result, 
as  52  per  cent  occur  under  5  years  of  age,  39  per  cent 
between  5  and  10,  and  only  5  per  cent  after  15  years. 

Typhoid  exhibits  no  claim  as  a  children's  disease,  as 
only  11  per  cent  occur  under  10  years  of  age,  and  only  3 
per  cent  are  reported  in  children  under  5  years. 

In  respect  to  tuberculosis,  very  few  cases  were  re- 
ported among  children;  but  we  must  remember  in  this 
connection  that  many  latent  general  cases  as  well  as 
some  glandular  and  bone  cases  often  fail  to  be  re- 
ported. 


CHAPTER  X 

TRANSMISSIBLE  DISEASES 

(Continued)1 

The  most  frequent  diseases  of  children  of  school 
age  are:  — 

1 1.  Measles. 

/  2.  Scarlet  fever. 

/     3.  Diphtheria. 

'     4.  Whooping-cough. 

5.  Mumps. 

6.  Chickenpox. 

7.  Smallpox. 

8.  Tuberculosis. 

9.  Hookworm  disease. 
10.  Infantile  paralysis. 
U.  Epidemic  meningitis. 

12.  Eye  diseases. 

13.  Skin  diseases. 

These  diseases  will  be  discussed  in  the  order  named, 
and  such  symptoms  and  complications  will  be  given  as 
will  be  useful  to  the  non-medical  reader. 

Further  details  concerning  the  transmissible  dis- 
eases of  children  may  always  be  obtained  in  a  useful 
form  from  the  various  state  boards  of  health,  as  well  as 
from  the  city  boards  of  health  of  the  larger  places. 
Some  of  these  the  reader  ought  to  procure  on  account 
of  their  practical  descriptions  and  their  readily  applic- 

1  The  writers  acknowledge  their  debt,  in  the  preparation  of  this 
section,  to  Dr.  James  Kerr's  Transmissible  Diseases. 


TRANSMISSIBLE  DISEASES  149 

able  methods  to  school  needs.  The  following  Boards  of 
Health  publish  particularly  important  and  interesting 
bulletins  and  reports :  — 

California  State  Board  of  Health  —  Sacramento. 
Minnesota  State  Board  of  Health  —  St.  Paul. 
Indiana  State  Board  of  Health  —  Indianapolis. 
North  Carolina  State  Board  of  Health  —  Raleigh. 
Michigan  State  Board  of  Health  —  Jackson. 
New  York  State  Board  of  Health  —  Albany. 

1.  Measles 

Measles  is  the  most  infectious  disease  of  childhood, 
as  well  as  the  commonest.  Practically  every  child  who 
is  exposed  takes  it  the  first  time  of  exposure.  It  is  most 
common  during  the  first  five  years  of  life,  but  is  often 
contracted  between  five  and  fifteen  years,  and  occas- 
ionally during  adult  life.  It  rather  rarely  occurs  during 
the  first  six  months  of  life,  but  occasionally  infection 
takes  place  before  birth  when  the  mother  is  suffering 
with  the  disease. 

While  measles  is  not  ordinarily  regarded  by  the  pub- 
lic as  a  serious  disease,  yet  it  is  safe  to  say  that  it  has  a 
general  mortality  of  not  less  than  4  per  cent.  Under 
bad  hygienic  conditions  this  mortality  is  often  higher 
and  may  reach  10  to  40  per  cent,  while  under  very 
favorable  conditions  the  percentage  may  be  very  low. 
The  highest  death  rate  is  reached  in  the  first  and  second 
years  of  life. 

In  Aberdeen,  Scotland,  the  statistics  for  twenty 
years  show  that  of  children  under  3  years  contracting 
measles  1  in  12  died,  while  the  average  rate  for  children 


150        HEALTH  WORK  IN  THE  SCHOOLS 

over  3  was  1  death  in  120  cases.  The  mortality  was 
highest  in  the  second  year,  1  in  9.  The  importance  of 
postponing  the  disease  is,  therefore,  obvious.  An  epi- 
demic of  measles  in  the  kindergarten  or  lower  grades 
should  always  be  regarded  with  apprehension.  The 
mortality  from  measles  is  always  higher  in  cases  in 
which  other  diseases  exist,  such  as  tuberculosis, 
syphilis,  general  malnutrition,  etc. 

Complications.  The  mortality  and  serious  morbidity 
of  measles  are  not  usually  due  to  the  toxins  of  the  dis- 
ease itself,  but  to  complications  accompanying  the  dis- 
ease. The  most  important  complications  are  those 
which  affect  the  respiratory  organs,  such  as  bronchitis, 
broncho-pneumonia,  and  tuberculosis.  Other  less  seri- 
ous complications  are  those  of  the  eyes,  ears,  nose,  and 
throat. 

After  effects.  The  most  serious  after-effect  of  measles 
is  tuberculosis.  This  occurs  in  a  considerable  number 
of  cases,  and  for  this  reason  the  child  should  always 
receive  the  best  possible  hygienic  care  after  recovery 
from  the  acute  stages. 

Symptoms.  Those  who  are  intimately  concerned 
with  children  ought  to  be  familiar  with  the  com- 
mon symptoms  of  children's  diseases.  The  following 
are  the  usual  and  most  evident  indications  of 
measles:  — 

1.  Catarrh  of  eyes,  nose,  throat.  The  child  seems  to  have 
a  cold. 

2.  General  lassitude. 

3.  Fever. 

4.  Eruption. 


TRANSMISSIBLE  DISEASES  151 

The  child  usually  begins  to  sneeze  and  blow  his  nose; 
his  eyes  soon  become  red  and  watery;  often  there  is 
considerable  cough;  sometimes  there  is  a  chill;  bluish- 
white  spots  surrounded  by  a  red  area  are  usually  seen 
on  the  mucous  membrane  of  the  mouth,  opposite  the 
double  teeth.  These  spots  make  their  appearance  be- 
fore the  rash  comes  out.  The  rash  usually  shows  about 
the  fourth  day  of  the  disease,  and  begins  on  the  face, 
neck,  and  head  most  frequently,  and  soon  extends  to 
the  trunk,  arms,  and  legs.  The  eruption  begins  as  pa- 
pules, or  small  reddish  spots,  occurring  in  groups  which 
have  tendency  to  form  irregular  crescents.  The  papules 
do  not  form  vesicles  (small  blisters),  or  pustules. 

Prevention.  The  great  infectivity  of  measles,  and  the 
fact  that  it  is  most  infectious  before  it  can  be  easily 
recognized,  make  its  prevention  a  matter  of  extreme 
difficulty.  While  compulsory  notification  cannot  have 
the  results  which  have  been  obtained  with  other  infec- 
tious fevers,  with  our  modern  methods  of  medical 
inspection  in  schools  much  good  ought  to  be  accom- 
plished. 

Closure  of  schools  has  been  found  a  very  unsatisfac- 
tory method,  and  is  productive  of  an  enormous  waste 
of  school  time.  To  secure  a  really  efficient  method  of 
protection  it  will  be  necessary  for  the  medical  officers 
of  schools  to  acquire  an  accurate  knowledge  of  the 
health  history  of  the  school  children.  This  may  be  ac- 
complished by  keeping  a  list  of  all  the  diseases  which 
the  children  have  had.  Provision  should  be  made  for 
this  on  the  child's  "Physical  Record  Card." 


152        HEALTH  WORK  IN  THE  SCHOOLS 

If  during  an  outbreak  of  measles  it  is  discovered  that 
certain  children  have  already  had  the  disease,  they 
need  not  be  excluded  from  school.  When  a  case  of 
measles  occurs  in  a  class,  all  children  who  have  not  had 
the  disease  should  be  at  once  excluded. 

Rules  on  this  point  have  been  formulated  for  the 
London  County  Council,  by  Dr.  Thomas,  as  follows:  — 

(a)  A  child  attending  other  than  an  infant  school,  who  has 
already  had  measles,  need  not  be  excluded. 

(6)  A  child  attending  other  than  an  infant  school,  who  has 
not  had  measles,  must  be  excluded  until  the  Monday  follow- 
ing the  expiration  of  fourteen  days  from  the  occurrence  of  the 
first  case. 

(c)  A  child  attending  an  infant  school,  whether  or  not  it 
has  measles,  is  excluded  for  the  same  period. 

Disinfection.  Disinfection  of  rooms  at  school  or  at 
home,  as  ordinarily  carried  out,  probably  has  little  or 
no  effect,  and  is  consequently  a  loss  of  time,  energy, 
and  money.  Ordinary  airing  and  cleaning  will  accom- 
plish all  that  is  necessary,  especially  if  the  rooms  are 
exposed  to  bright  sunlight.  Bedclothing  and  personal 
clothing  should  be  thoroughly  washed  and  aired. 

Willful  exposure.  Children  should  be  protected  as 
long  as  possible  against  infection  with  measles.  It 
must  not  be  forgotten  that  in  any  case,  whether  young 
or  old,  complications,  such  as  tuberculosis,  pneumonia, 
meningitis,  ear  disease,  and  eye  troubles,  may  occur. 
The  individual  who  willfully  exposes  a  child  to  measles 
(a  procedure  which  is  far  from  infrequent)  is  guilty 
of  criminal  ignorance. 


TRANSMISSIBLE  DISEASES  153 

2.  Scarlet  Fever 

Scarlet  fever  is  one  of  the  most  serious  of  the  diseases 
which  affect  children,  and  its  after  effects  are  particu- 
larly to  be  dreaded.  It  occurs  at  all  seasons,  but  in  epi- 
demic form  is  most  likely  to  occur  during  the  fall  and 
winter  months. 

Very  little  is  known  concerning  the  relation  of  tem- 
perature and  climate  to  this  disease,  but  like  other 
eruptive  diseases  of  childhood  it  is  usually  less  severe 
in  warm  than  in  cold  climates. 

Age  occurrence.  Scarlet  fever  is  most  common  in 
children  between  5  and  10  years  of  age,  and  more  cases 
occur  at  the  age  of  6  years  than  at  any  other.  Under  1 
year  and  over  15  years  of  age  relatively  few  cases  of 
scarlet  fever  are  observed.  The  disease  occasionally 
manifests  itself  in  adult  life,  but  out  of  167,840  cases 
recorded  by  Ford  Carger  there  were  only  77  in  indi- 
viduals past  50  years  of  age.  There  exists  a  great  differ- 
ence in  the  degree  of  susceptibility  of  individuals 
toward  this  disease,  some  being  practically  immune, 
while  others  exhibit  a  high  degree  of  predisposition  to 
infection  with  it. 

Modes  of  infection.  As  with  most  other  diseases,  we 
now  know  that  scarlet  fever  is  most  often  spread  by 
direct  contact.  Although  the  specific  organism  causing 
the  disease  has  not  yet  been  positively  identified,  it  is 
probably  present  in  the  secretions  of  the  nose  and 
throat.  There  is  reason  to  believe  that  the  organism, 
whatever  it  is,  may  under  some  conditions  be  spread  by 


154        HEALTH  WORK  IN  THE  SCHOOLS 

carriers.  Epidemics  sometimes  occur  through  infected 
milk  supplies.  Air  infection  plays  little  or  no  part  in 
spreading  this  disease,  and  there  is  no  evidence  that 
water  ever  carries  it. 

In  respect  to  f  omites,  Kerr  remarks  that  these  may 
play  considerable  part  in  the  dissemination  of  infec- 
tion. He  further  states  that  the  clothes  of  a  patient  are 
highly  infectious,  and  may  remain  so  for  a  long  period. 
It  is  difficult,  he  says,  to  accept  without  some  reserve 
the  tragic  stories,  so  frequently  related,  of  infection 
clinging  to  clothes  or  toys  for  over  twenty  years  and 
then  breaking  out  when  the  articles  are  disturbed. 
There  can  be  little  doubt,  however,  that  clothing, 
books,  letters,  toys,  and  bedding  can  retain  the  virus 
alive  for  months,  especially  if  they  are  excluded  from 
light  and  air.1 

Chapin,  however,  is  disinclined  to  place  much  reli- 
ance in  the  various  alleged  cases  of  f omite  infection  in 
any  of  the  transmissible  diseases,  and  says  that  the 
amount  of  disease  caused  in  this  way  is  relatively  very 
small.  We  have  no  need  for  such  a  theory  and  a  much 
more  satisfactory  explanation  is  at  hand.2 

This  explanation  Chapin  finds  in  the  existence  of 
healthy  carriers  and  atypical  cases.  He  also  points  out 
that  if  infection  from  fomites  really  occurred  as  often 
as  has  been  supposed,  transmissible  diseases  would  be 
much  more  prevalent  than  they  are.  There  is  no  good 
epidemiological  evidence  that  diseases  are  spread  by 

1  Kerr,  James,  Infectious  Diseases. 

2  Chapin,  C.  V.,  Sources  and  Modes  of  Infection. 


TRANSMISSIBLE  DISEASES  155 

fomites  except  in  cases  due  to  spore-forming  bacteria. 
In  schools,  scarlet  fever  is  not  spread  as  readily  as  mea- 
sles or  diphtheria. 

Duration  of  infectiousness.  The  patient  is  capable  of 
transmitting  the  disease  from  the  time  his  symptoms 
are  first  noted  and  until  the  catarrhal  stage  has  disap- 
peared. As  long  as  there  is  any  inflammation  in  the 
nose  or  throat,  or  any  discharge  from  the  ears,  the 
individual  is  infectious.  It  is  also  probable  that  infec- 
tion spreads  from  suppurating  glands  in  the  neck.  It 
has  always  been  supposed  that  the  desquamating 
(peeling)  skin  was  highly  infectious,  but  to-day  this  is 
regarded  less  seriously  than  formerly,  although  the 
possibility  of  infection  from  this  source  cannot  yet  be 
entirely  ignored. 

On  an  average,  a  child  will  be  a  possible  source  of 
infection  for  about  six  weeks,  but  each  individual  case 
must  be  judged  by  the  disappearance  of  the  catarrhal 
symptoms  of  the  nose  and  throat,  the  ear  discharge, 
the  discharge  from  the  lymphatic  glands,  and  last,  and 
probably  of  least  importance,  the  disappearance  of 
peeling.  After  exposure,  a  susceptible  individual  should 
be  isolated  for  about  ten  days,  as  a  matter  of  precau- 
tion. 

Period  of  Incubation.  The  symptoms  of  scarlet  fever 
develop  rapidly,  the  period  of  incubation  in  the  major- 
ity of  cases  not  exceeding  seven  days.  More  often  it  is 
not  more  than  four  days,  and  it  is  probable  that  most 
cases  do  not  require  over  two  or  three  days  before  they 
exhibit  symptoms  of  the  disease. 


156        HEALTH  WORK  IN  THE  SCHOOLS 

Early  symptoms.  For  the  guidance  of  the  non-medi- 
cal reader  the  following  early  symptoms  of  scarlet 
fever  are  given:  — 

A.  General  B.  Specific 

Fever.  Quick  change  from  good  health  to 

Sore  throat.  sickness. 

Headache.  Abrupt  rise  of  temperature. 

Vomiting.  Rapid  pulse  out  of  proportion  to 

Chilliness.  fever.  v<  • 

Malaise.  Sore  throat. 

Of  these  symptoms  the  first  four  are  the  most  signifi- 
cant in  children.  Vomiting  and  sore  throat  are  almost 
invariably  present.  The  rash  usually  appears  in  about 
twenty-four  hours  from  the  time  of  the  appearance  of 
the  first  symptoms.  It  usually  appears  first  in  the  neck 
and  chest,  gradually  spreading  downward  to  the  arms, 
trunk,  and  legs.  The  rash  consists  of  minute  points 
on  a  surface  somewhat  less  red.  The  points  are  very 
closely  set  together,  are  no  larger  than  half  a  pinhead, 
and  are  not  much  raised,  at  least  not  sufficiently  to  be 
felt  by  the  finger.  The  appearance  of  the  tongue  is 
often  somewhat  characteristic.  At  first  it  is  heavily 
coated  and  white.  Later  it  has  a  "white  strawberry'* 
appearance.  This  is  succeeded  by  a  "red  strawberry" 
stage. 

Mortality.  Scarlet  fever  has  not  a  very  high  mor- 
tality. In  England  it  is  said  to  be  from  2  to  5  per  cent. 
This  varies  greatly,  however,  with  the  age  of  the  pa- 
tient. For  children  under  1  year  of  age  it  may  reach  as 
high  as  21  per  cent,  and  for  children  between  1  and  2 


TRANSMISSIBLE  DISEASES  157 

years  of  age,  16  per  cent.  In  general,  the  younger  the 
patient,  the  higher  the  death  rate.  From  10  to  15  years 
of  age  is  said  to  be  the  period  of  fewest  fatalities. 

Complications.  Scarlet  fever  has  associated  with  it 
more  serious  complications  than  has  any  other  of  the 
eruptive  diseases  of  childhood.  Of  these  complications 
the  following  are  the  most  important:  — 

1.  Nephritis  (Bright 's  disease). 

2.  Arthritis  (articular  rheumatism). 

3.  Heart  disease :  — 

(a)  Endocarditis. 

(b)  Pericarditis. 

4.  Adenitis  (inflammation  of  the  lymphatic  glands). 

5.  Otitis  media  (inflammation  of  the  middle  ear). 

6.  Rhinitis  (inflammation  of  the  nasal  passages). 

7.  Tonsillitis. 

8.  Broncho-pneumonia. 

9.  Meningitis. 
10.  Diphtheria. 

Nephritis,  or  Bright's  disease,  is  not  rare  in  cases  of 
scarlet  fever,  even  in  mild  cases,  and  sometimes  it  per- 
sists as  a  permanent  organic  disease  of  the  kidneys.  It 
is  not  as  yet  clear  whether  this  complication  is  caused 
by  the  toxin  or  by  the  germ  of  scarlet  fever,  but  it  is 
probable  that  both  play  an  important  part. 

After  10  years  of  age  nephritis  is  rarely  encountered 
as  a  complication.  On  the  other  hand,  when  Bright's 
disease  occurs  in  children  under  ten,  scarlet  fever  ought 
to  be  thought  of  as  a  possible  explanation,  as  it  may  be 
present  in  a  mild,  unrecognized  form.  Kidney  compli- 
cations probably  occur  in  not  less  than  10  per  cent  of 
the  cases. 


158        HEALTH  WORK  IN  THE  SCHOOLS 

Arthritis,  or  rheumatism  of  the  joints,  is  said  to 
occur  in  about  4  per  cent  of  all  cases,  and  in  more  than 
half  of  all  these  it  appears  in  children  past  10  years  of 
age.  Muscular  rheumatism  also  appears  in  some  scarlet 
fever  cases  and  is  probably  caused  by  the  toxins  of  the 
disease. 

Heart  complications  are  not  very  common,  but  when 
they  do  occur  they  are  most  often  coincident  with 
rheumatism.  Of  22,096  cases  of  scarlet  fever  observed, 
endocarditis  —  inflammation  of  the  lining  of  the  heart 
—  appeared  in  only  0.58  per  cent  of  the  entire  number. 

The  commonest  complication  of  all  in  scarlet  fever 
is  otitis  media,  or  inflammation  of  the  middle  ear.  Usu- 
ally about  12  per  cent  of  cases  are  observed  to  be  thus 
affected.  The  germs  setting  up  the  inflammation  may 
be  carried  either  through  the  eustachian  tube  from  the 
nose  and  throat,  or  by  means  of  the  blood. 

The  discharge  which  takes  place  from  one  or  both 
ears  may  be  transient  in  character,  or  may  last  for 
months  or  years.  This  condition  may,  of  course,  pro- 
duce more  or  less  permanent  deafness,  especially  in 
cases  which  do  not  receive  proper  treatment.  It  seems 
very  probable  that  discharging  ears  may  be  the  cause 
of  scarlet  fever  infections  in  many  cases.  Sometimes  a 
mother  will  attribute  a  case  of  scarlet  fever  in  the 
family  to  the  fact  that  some  clothing  or  toys  which 
were  not  completely  disinfected  at  the  time  of  occur- 
rence of  a  previous  case,  perhaps  years  before,  had 
been  recently  unpacked  and  handled.  An  investiga- 
tion in  such  cases  often  demonstrates  the  presence  of  a 


TRANSMISSIBLE  DISEASES  159 

discharging  ear  in  the  previous  case,  which  has  per- 
sisted since  the  time  of  the  scarlet  fever  attack.  It  is 
far  more  reasonable  to  attribute  infection  to  such  a 
source  rather  than  to  any  organisms  remaining  active 
for  a  long  period  in  clothing. 

Diphtheria,  following  scarlet  fever  or  associated  with 
it,  is  often  observed.  This  may  in  part  be  explained  by 
the  fact  that  the  child  may  have  been  a  diphtheria  car- 
rier and  that  the  germs  have  become  active  during  the 
attack  of  scarlet  fever,  or  that  the  resistance  has  be- 
come reduced  because  of  it.  Until  antitoxin  was  em- 
ployed, this  complication  was  the  cause  of  a  fearful 
mortality,  but  with  its  early  and  general  use  the  danger 
has  been  greatly  reduced. 

3.  Diphtheria 

Diphtheria  is  one  of  the  few  diseases  for  which  a 
specific  treatment  has  been  discovered.  The  use  of 
antitoxin  has  not  only  greatly  reduced  the  mortality 
from  the  disease,  but  has  also  decreased  the  seriousness 
of  sickness  incident  to  it.  The  bacillus  which  causes 
diphtheria  was  discovered  by  Klebs  in  1883,  and  much 
of  the  modern  treatment  of  germ  diseases  dates  back 
to  this  period. 

Age.  Diphtheria  occurs  most  frequently  during  the 
first  ten  years  of  life.  Under  1  year  of  age  it  is  not  com- 
mon, but  it  is  met  more  frequently  during  the  period 
from  %  to  5  years  than  at  any  other  time.  After  12 
years  of  age  it  is  relatively  uncommon. 

Modes  of  infection.  Direct  contact  explains  satisfac- 


160        HEALTH  WORK  IN  THE  SCHOOLS 

torily  the  greatest  number  of  cases,  although  indirect 
contact,  from  the  common  use  of  such  articles  as  pen- 
cils, handkerchiefs,  towels,  common  eating-utensils, 
and  the  like,  may  account  for  a  good  many  cases.  Some 
epidemics  appear  to  have  originated  in  infected  milk 
supplies. 

Carriers  are  very  common  in  diphtheria,  and  the  con- 
trol of  the  sick  cases  and  carriers  is  usually  all  that  is 
necessary  to  stop  an  epidemic  of  this  disease.  Chapin 
thinks  that  perhaps  1  or  2  per  cent  of  the  population 
e  germp  of  diphtheria  constantly  in  the  nose 

throat.  Among  those  that  have  been  in  close  con- 
tact with  diphtheria  cases  the  percentage  of  carriers 
is  usually  pretty  high;  10  to  15  per  cent  is  not  an  un- 
usual proportion  under  such  conditions.  In  schools 
where  there  have  been  epidemics  of  diphtheria  it  has 
not  been  uncommon  to  discover  that  from  25  to  50  per 
cent  of  the  well  children  are  carriers  of  the  bacillus,  and 
are  therefore  capable  of  spreading  the  disease. 

It  often  happens  that  atypical  cases  of  diphtheria 
occur,  cases  which  are  so  mild  in  character  that  they 
may  even  be  overlooked  by  physicians.  From  mild 
cases  of  this  type  serious  cases  and  even  epidemics  may 
result  through  the  infection  of  susceptible  individuals. 
Every  case  of  definite  sore  throat  ought  to  be  regarded 
as  a  possible  case  of  diphtheria,  until  proved  not  to  be 
one.  The  only  possible  way  to  determine  the  facts  is 
by  use  of  the  culture  method;  i.e.,  the  throat  must  be 
swabbed  and  the  bacteria  grown  on  an  artificial  culture 
medium  for  twelve  to  twenty-four  hours,  and  then 


MM 


TRANSMISSIBLE  DISEASES  161 

examined  bacteriologically.  Every  competent  health 
officer  now  has  facilities  for  such  diphtheria  examina- 
tions, and  the  public  ought  to  make  free  use  of  the 
opportunities  thus  afforded. 

It  should  never  be  forgotten  that  diphtheria  and 
scarlet  fever  are  often  associated.  Therefore,  in  scarlet 
fever,  cultures  from  the  throat  should  be  taken  as  a 
matter  of  precaution. 

The  old  idea  that  diphtheria  may  be  spread  by  defec- 
tive drains,  "sewer  gas,"  stagnant  water,  "bad  air," 
and  the  like  needs  only  to  be  mentioned  to  be  con- 
demned as  a  superstition.  Fomites  play  no  more  im- 
portant part  in  spreading  diphtheria  than  they  do  in 
most  other  transmissible  diseases.  For  infection  to  be 
carried  in  this  manner  the  infective  material  must  be 
relatively  fresh.  The  domestic  cat  sometimes  suffers 
from  diphtheria,  and  there  is  sufficient  evidence  to  lead 
us  to  believe  that  this  animal  may  infect  human  beings 
who  come  into  direct  contact  with  it.  Diphtheritic 
patches  and  ulcers  sometimes  occur  on  the  udders  of 
cows,  and  a  few  milk  epidemics  have  been  traced  to 
such  sources. 

It  is  not  possible  to  state  just  how  long  it  takes  the 
disease  to  develop  in  a  suceptible  person  after  exposure, 
but  there  is  good  reason  to  believe  that  it  sometimes 
appears  as  soon  as  twenty-four  hours.  On  the  other 
hand,  the  germs  may  be  carried  in  the  nose  or  throat 
for  days,  weeks,  or  months,  before  any  symptoms  ap- 
pear, while  in  other  instances,  as  we  have  already 
learned,  a  carrier  may  show  no  symptoms  of  sickness  at 


162        HEALTH  WORK  IN  THE  SCHOOLS 

«  • 

all.  Ordinarily  about  two  or  three  days  will  be  required 
for  the  disease  to  develop. 

Symptoms.  The  prominent  and  common  symptoms 
of  diphtheria  are  as  follows:  — 

Fever. 

Headache. 

Malaise. 

Chilliness. 

Lassitude. 

Rapid  pulse. 

Loss  of  appetite. 

Sore  throat. 

Patches  of  whitish  membrane  in  the  throat. 

Complications.  Broncho-pneumonia  may  occur  and 
is  always  a  very  serious  complication.  Inflammation 
of  the  middle  ear  (otitis  media)  is  not  rare,  and  some- 
times the  discharge  contains  diphtheria  germs. 

Paralysis  of  various  parts  is  not  uncommon,  and  is 
due  to  the  toxins  of  the  disease.  Paralysis  of  the  heart 
is  the  cause  of  many  of  the  sudden  deaths  in  attacks  of 
diphtheria,  or  during  early  convalescence.  In  some 
cases  the  muscles  of  the  eyes  are  affected;  in  others 
those  of  the  legs,  arms,  throat,  face,  or  the  muscles  of 
respiration.  Sometimes  the  paralysis  occurs  in  several 
parts  of  the  body. 

Mortality.  Before  the  use  of  antitoxin,  the  death  rate 
from  diphtheria  was  very  high,  often  reaching  25  or  30 
per  cent  of  the  cases,  while  25  to  40  per  cent  was  not 
unknown.  With  the  early  use  of  antitoxin  this  terrible 
mortality  has  been  reduced  to  from  3  to  14  per  cent, 
depending  upon  the  severity  of  the  epidemic.    If  a 


TRANSMISSIBLE  DISEASES  163 

diphtheria  case  is  treated  with  antitoxin  serum  the  first 
day,  death  very  seldom  occurs;  but  every  day  of  delay 
adds  to  the  risk.  It  should  be  understood  that  antitoxin 
also  affords  protection  against  diphtheria  in  the  cases 
of  exposed  persons,  and  it  is  especially  important  to 
administer  it  in  the  case  of  those  who  carry  the  germs 
in  the  nose  or  throat. 

Control  of  an  epidemic  of  diphtheria.  A  matter  of 
prime  importance  in  the  control  of  diphtheria  is  to 
recognize  the  cases  early,  and  isolate  them.  Next  in 
importance  is  the  discovery  of  carriers,  and  the  isola- 
tion of  these  also.  Last  of  all,  no  cases  of  either  class 
should  be  allowed  to  mingle  with  other  children  (or 
adults)  until  examination  proves  that  the  germs  of  the 
disease  have  entirely  disappeared. 

It  is  probably  never  necessary  for  a  school  to  be 
closed  if  the  precautions  just  described  are  carefully 
observed,  though  it  is,  of  course,  necessary  to  clean  and 
disinfect  the  desk  and  personal  belongings  of  the  chil- 
dren who  are  known  to  have  been  infected. 

Conclusions  from  the  investigation  of  an  epidemic  in  a 
Berkeley  (California)  School1 

The  existence  of  an  epidemic  of  diphtheria  in  one  of 
the  schools  of  Berkeley  afforded  an  opportunity  to 
make  an  exhaustive  trial  of  the  control  of  diphtheria 
by  strictly  laboratory  methods. 

The  local  health  authorities  first  became  alarmed 

1  Abstracted  from  a  Report  by  Archibald  A.  Ward  and  Margaret 
Henderson. 


164        HEALTH  WORK  IN  THE  SCHOOLS 

about  diphtheria  in  Berkeley  early  in  November.  In 
October  five  cases  were  reported,  four  of  them  from 
the  Lincoln  School  District.  In  the  first  half  of 
November  ten  cases  were  reported,  nine  of  them  from 
the  Lincoln  School  District  and  two  of  them  resulting 
in  death.  Besides  these  reported  cases,  there  were  un- 
official rumors  of  many  others. 

A  great  clamor  arose  among  the  inhabitants  of  the 
region,  and  those  of  other  parts  of  Berkeley  who  heard 
of  the  epidemic,  insisting  on  the  closing  of  the  school 
until  the  diphtheria  should  be  over.  But  it  was  deemed 
wiser  to  keep  the  school  open,  excluding  all  children 
who  showed  diphtheria  bacilli  in  their  throats.  If  the 
school  closed,  all  children  would  go  out  of  the  control 
and  observation  of  the  health  officer.  If  it  were  open, 
they  would  remain  segregated,  new  cases  would  be 
easily  traced,  and  old  cases  more  easily  kept  quaran- 
tined until  free  from  infection.  It  was,  therefore,  de- 
cided to  examine  every  child  in  the  school,  excluding 
all  those  showing  diphtheria  bacilli,  and  readmitting 
infected  ones  only  after  two  negative  cultures  had 
been  obtained  from  them  at  an  interval  of  at  least  a 
week. 

The  school  was  then  closed  for  the  three  days  neces- 
sary to  examine  the  cultures,  and  when  it  was  reop- 
ened, those  children  showing  diphtheria  bacilli  were 
sent  home,  together  with  their  sisters  and  brothers. 
No  attempt  was  made  to  disinfect  the  school  at  any 
time  during  the  epidemic.  The  principal  undertook  to 
see  that  the  desks  of  the  children  found  to  be  infected 


TRANSMISSIBLE  DISEASES  165 

were  washed  in  a  4  per  cent  formalin  solution,  and  that 
their  books  and  pencils  were  sent  home  with  them.  Be- 
yond this  nothing  was  done  in  the  way  of  disinfection 
at  any  time. 

About  475  children  were  examined,  and  27,  or  about 
5  per  cent,  were  found  positive.  There  was  no  attempt 
to  quarantine  these  children;  they  were  merely  ex- 
cluded from  the  school. 

The  first  examination  did  not  stop  the  epidemic  and 
it  was  decided  that  the  second  one  must  be  made  more 
stringent.  Various  changes  were  made,  for  this  reason, 
in  the  technique.  Cultures  were  taken  from  the  throat, 
as  before,  but,  in  addition,  cultures  were  also  made 
from  the  nose,  on  the  same  tube  of  blood  serum. 

In  this  second  examination,  77  of  the  550  children, 
or  14  per  cent,  were  found  to  be  harboring  diphtheria 
bacilli.  This  meant  the  exclusion  from  school  of  a  total 
of  125  children. 

Conclusions 

(1)  The  epidemic  was  due  to  three  factors:  (a)  Exist- 
ence of  mild  cases  of  diphtheria  which,  because  of  the 
lack  of  bacteriological  examination,  had  gone  un- 
recognized as  diphtheria;  (b)  the  insufficient  length  of 
quarantine  in  clinical  cases;  (c)  germ  cases  following 
exposure  and  never  showing  clinical  symptoms  (car- 
riers). 

(2)  Attempts  to  isolate  all  infected  children  had  no 
effect  on  the  course  of  the  epidemic,  so  long  as  throat 
cultures  only  were  made.  When  both  nose  and  throat 


166        HEALTH  WORK  IN  THE  SCHOOLS 

cultures  were  made  and  all  the  children  showing  posi- 
tive cultures  were  quarantined,  the  epidemic  stopped. 

(3)  It  is  extremely  important,  in  times  of  danger 
from  diphtheria,  that  every  sore  throat,  no  matter  how 
far  it  may  seem  to  be  from  diphtheria,  be  regarded  as 
suspicious  until  a  bacteriological  examination  has 
proved  it  to  be  otherwise. 

(4)  It  is  such  a  frequent  occurrence  to  have  a  posi- 
tive culture  follow  a  negative  one  that  at  least  two 
negatives  should  be  demanded  for  release  from  quaran- 
tine. No  case  should  be  released  on  clinical  signs  alone. 

(5)  It  is  possible  to  stop  epidemic  diphtheria  in  a 
public  school  by  regulation  of  attendance  by  means  of 
bacteriological  findings. 

4.  Whooping-cough 

Until  recently  the  organism  of  whooping-cough  was 
unknown.  Now  it  is  generally  recognized  as  an  influ- 
enza-like bacillus  called  the  "Bordet  Bacillus."  Whoop- 
ing-cough is  very  largely  a  disease  of  infancy  and  early 
childhood.  If  a  child  can  be  protected  against  the  dis- 
ease until  he  is  five  or  six  years  old,  his  chances  of  tak- 
ing it  are  very  greatly  reduced.  The  greatest  number  of 
cases  probably  occur  in  the  fourth  year,  but  the  disease 
is  common  in  children  under  1  year  of  age,  and  some- 
times occurs  in  babies  less  than  2  months  old.  After  10 
years  of  age,  whooping-cough  is  relatively  rare,  but 
occasionally  adults  are  affected,  and,  in  rare  cases,  the 
aged. 

Mode  of  transmission.    Whooping-cough  is  trans- 


TRANSMISSIBLE  DISEASES  167 

mitted  very  largely,  if  not  exclusively,  by  direct  or 
indirect  contact.  The  disease  is  extremely  contagious, 
although  not  as  much  so  as  measles.  The  period  of  in- 
fectiousness extends  from  the  earliest  catarrhal  symp- 
toms, which  first  appear  as  an  ordinary  cold,  until  the 
cough  has  ceased.  One  attack  of  whooping-cough  prac- 
tically protects  for  life  against  reinfection. 

Not  much  is  positively  known  about  the  period  of 
development  of  whooping-cough,  but  this  probably 
varies  from  one  or  two  days  to  two  weeks.  If,  after 
exposure,  the  disease  has  not  appeared  within  fifteen 
days,  there  is  little  or  no  danger  that  it  will  appear  at 
all. 

Symptoms.  It  is  highly  important  to  understand 
that  whooping-cough  usually  begins  much  like  an  ordi- 
nary cold,  with  cough,  and  that  it  is  often  if  not  usually 
unrecognized  for  a  number  of  days.  Generally  the 
cough  becomes  progressively  more  severe,  and  by  the 
end  of  the  first  or  second  week  the  paroxysmal  charac- 
ter of  the  cough  makes  the  case  a  clear  one. 

This  paroxysm  associated  with  the  cough  may  occur 
a  few  or  many  times  during  the  twenty-four  hours. 
The  child  coughs  violently  in  quick  succession  and  is 
unable  to  get  his  breath;  his  face  becomes  very  red  or 
even  purple,  and  he  presents  a  rather  alarming  appear- 
ance. At  last  the  breath  is  drawn  in  with  a  "whoop," 
which  may  or  may  not  end  the  particular  spasm. 
Vomiting  usually  occurs  at  the  end  of  the  "whoop," 
but  sometimes  precedes  it. 

Duration.  One  of  the  many  unfortunate  features  of 


168        HEALTH  WORK  IN  THE  SCHOOLS 

whooping-cough  is  its  long  duration.  On  the  average 
this  covers  a  period  of  five  or  six  weeks.  The  "whoop" 
may  persist  for  a  much  longer  period  than  this,  and 
sometimes  it  continues  for  several  months,  or  even  for 
a  year. 

Complications.  Whooping-cough  should  be  regarded 
seriously  for  several  reasons.  First  of  all,  it  keeps  the 
child  out  of  school  for  several  weeks  or  months;  second, 
it  causes  a  tremendous  strain  of  the  heart  and  lungs; 
third,  it  has  many  possible  complications.  Among 
these  are:  — 

Hemorrhages  in  the  eyes,  nose,  bronchial  tubes,  and  occa- 
sionally in  other  localities,  including  the  ear,  skin,  and  brain. 

Digestive  disturbances. 

Hernia  (rupture). 

Broncho-pneumonia. 

Nervous  complications  of  various  kinds,  such  as  convul- 
sions, and,  in  rare  cases,  paralysis. 

Heart  strain  not  infrequently  occurs  in  severe  cases.  This 
may  result  in  permanent  injury,  but  more  often  it  is  of  tem- 
porary character. 

Tuberculosis  often  follows  long  attacks  of  broncho-pneu- 
monia, and  is  much  to  be  dreaded  in  such  cases. 

Control.  Whenever  there  is  an  epidemic  of  whooping- 
cough,  every  child  with  a  suspicious  cold  and  cough 
ought  to  be  excluded  from  school  and  kept  under  ob- 
servation for  about  two  weeks.  Such  a  precaution  will 
greatly  reduce  the  number  of  cases  in  a  school.  Chil- 
dren who  develop  the  disease  should  be  isolated  for  a 
period  of  about  six  weeks,  and  it  is  unsafe  to  allow 
them  to  mingle  with  other  children  until  the  "whoop" 
has  disappeared.  A  slight  cough  without  the  "whoop " 


TRANSMISSIBLE  DISEASES  169 

may  ordinarily  be  ignored,  as  this  often  persists  long 
after  all  danger  of  infection  has  passed.  A  bacterio- 
logical examination  for  the  presence  of  the  specific 
germ  of  the  disease  will  of  course  settle  the  question  of 
the  infectiousness  of  a  case. 

All  expectorations  should  be  carefully  destroyed  by 
disinfectants,  or  by  burning.  Disinfection  of  articles 
which  may  carry  infection  ought  to  be  practiced  as  a 
matter  of  precaution,  although  there  is  probably  rela- 
tively little  danger  of  infection  from  such  sources. 

Children  from  families  in  which  there  is  whooping- 
cough  need  not  be  excluded  from  school,  if  they  them- 
selves have  had  the  disease.  If  they  have  not,  unless 
over  10  years  of  age,  they  should  be  excluded  for  at 
least  two  or  three  weeks.  After  this  they  may  return, 
but  should  be  carefully  watched  for  symptoms. 

5.  Mumps 

Mode  of  transmission.  While  the  specific  germ  of 
mumps  has  not  been  discovered,  there  is  no  doubt  as  to 
the  existence  of  such  an  organism.  Some  regard  the  dis- 
ease as  a  septicaemia,  or  general  infection  in  the  blood. 

Season  has  little  to  do  with  the  occurrence  of  mumps, 
but  age  is  a  factor  of  much  importance.  The  disease  is 
not  common  in  the  very  young,  or  in  those  past  middle 
life.  It  most  often  occurs  between  the  ages  of  5  and  15 
years.  In  the  Berkeley,  California,  investigation (Hoag 
and  Hall),  50  per  cent  of  the  cases  occurred  between  5 
and  10  years,  and  26  per  cent  between  10  and  15  years. 

We  are  rapidly  learning  that  most  infectious  diseases 


/ 


170        HEALTH  WORK  IN  THE  SCHOOLS 

are  spread  directly  or  indirectly  from  the  secretions  of 
the  nose  and  throat,  and  in  this  respect  mumps  appears 
to  offer  no  exception. 

Mumps  may  be  called  a  school  disease.  Epidemics  in 
high  schools  and  colleges  are  not  uncommon,  and  they 
often  appear  also  in  barracks.  The  disease  is  not  very 
contagious,  the  susceptibility  of  children  to  it  being 
much  less  than  in  the  case  of  other  transmissible  dis- 
eases of  childhood. 

It  is  contagious  from  the  time  of  the  appearance  of 
the  earliest  symptoms,  and  probably  usually  remains 
so  for  several  days  after  the  disappearance  of  the 
swelling.  The  period  of  incubation  varies  considerably, 
but  is  usually  from  three  days  to  three  weeks,  with  an 
average  period  of  about  twenty  days  after  exposure. 

Symptoms.  Often  the  swelling  of  the  parotid  glands 
(at  the  angle  of  the  jaw)  is  the  first  symptom.  In  some 
severe  cases  there  may  be  headache,  pains  in  the  back 
and  legs,  and  vomiting  and  fever  for  about  one  day 
before  the  appearance  of  the  glandular  swelling.  Pain 
often  precedes  the  swelling  of  the  parotid  glands,  and 
the  glands  may  swell  on  one  or  both  sides  of  the  neck. 
Usually  the  swelling  reaches  its  limit  in  two  or  three 
days,  and  then  remains  stationary  for  a  few  days,  when 
it  slowly  decreases.  Ordinarily  the  swelling  completely 
subsides  in  a  week  or  ten  days  from  the  beginning  of 
the  process.  Other  glands  of  the  neck  are  occasionally 
affected,  but  in  any  event  the  course  of  the  disease  is 
nearly  always  mild  and  uneventful. 

As  a  complication,  swelling  of  the  sexual  glands  (tes- 


TRANSMISSIBLE  DISEASES  171 

tides  or  ovaries)  occasionally  occurs.  This  is  rarely 
observed  before  puberty,  but  after  this  period  it  may 
appear  in  either  sex.  Other  complications  are  not  often 
met  with,  and  need  not  be  mentioned  here. 

Control.  In  the  majority  of  cases  the  symptoms  will 
not  appear  until  at  least  a  week  after  exposure.  Con- 
sequently an  exposed  child  who  has  not  had  the  disease 
need  not  be  isolated  during  the  first  week.  After  that 
it  is  well  to  practice  isolation  for  a  period  of  about  two 
weeks.  Second  attacks  are  possible,  but  are  so  infre- 
quent as  to  be  negligible.  Disinfection,  except  of  desks 
and  the  personal  belongings  of  the  child,  need  not  be 
practiced. 

6.  Chickenpox 

While  chickenpox  is  usually  mild  and  harmless,  yet 
this  is  not  always  the  case,  and  in  exceptional  instances 
some  severe  complications  may  arise.  A  point  of  par- 
ticular importance  is  that  it  is  frequently  confused 
with  smallpox,  every  physician  having  seen  cases  of 
beginning  smallpox  diagnosed  "chickenpox."  At  one 
time  it  was  supposed  that  chickenpox  was  a  mild  form 
of  smallpox,  but  since  about  1870  there  has  been  no 
controversy  in  regard  to  this  point. 

Varicella,  or  chickenpox,  originates  through  infec- 
tion only,  but  just  how  this  comes  about  we  are  still  in 
doubt.  Most  authorities  doubt  if  this  disease  is  ever 
carried  by  a  third  person  or  by  fomites.  It  is  also 
doubtful  if  air  transmission  plays  any  part  in  the  spread 
of  the  disease. 


172        HEALTH  WORK  IN  THE  SCHOOLS 

The  contagiousness  begins  as  soon  as  the  eruption 
appears,  and  probably  continues  until  all  crusts  have 
fallen  from  the  skin. 

It  is  rare  that  an  individual  ever  has  more  than  one 
attack,  but  this  does  occur  occasionally.  Chickenpox 
is  a  universal  disease,  and  is  rarely  altogether  absent 
from  large  centers  of  population.  It  occurs  most  often 
in  the  epidemic  form,  soon  after  the  opening  of  schools. 

Chickenpox  is  so  rare  in  adults  that  every  such  case 
ought  to  be  very  carefully  distinguished  from  smallpox. 

The  early  symptoms  are:  — 

Fever. 

Loss  of  appetite. 

Restlessness. 

Malaise. 

Vomiting. 

Nosebleed. 

The  eruption  usually  comes  out  in  from  one  to  four 
days  after  the  appearance  of  the  first  symptoms,  but 
sometimes  the  noticeable  symptoms  and  the  eruption 
seem  to  occur  simultaneously.  The  eruption  begins  as 
small  papules  (little  red  spots),  which  soon  change  into 
vesicles  (little  blisters).  These  vesicles  soon  dry  and 
in  a  day  or  so  leave  scabs,  which  usually  fall  off  after 
two  or  three  days.  All  stages  of  the  eruption  may  be 
observed  on  the  body  at  the  same  time. 

Complications.  Complications  are  very  rare,  but  do 
occur  in  a  number  of  different  forms,  as  follows:  — 

/A'^jp  Nephritis  (kidney  disease). 

Arthritis  (rheumatism). 
Paralysis. 


TRANSMISSIBLE  DISEASES  173 

Chorea. 
Infections. 
Gangrene  of  skin. 

Control.  The  child  should  be  excluded  from  school 
from  the  time  of  the  earliest  symptoms  until  the  scabs 
have  disappeared. 

7.  Smallpox 

An  exact  knowledge  of  smallpox  is  important,  be- 
cause in  mild  cases  it  is  easily  confused  with  chicken- 
pox.  It  not  infrequently  happens  that  a  case  of  small- 
pox is  so  mild  that  it  does  not  even  present  the  slight 
symptoms  common  to  chickenpox. 

Onset  of  the  disease.  In  smallpox  there  is  always  some 
fever  for  a  period  of  about  three  days  before  any  other 
marked  symptoms  appear.  With  fever  there  is  associ- 
ated headache,  general  malaise,  and  often  such  symp- 
toms as  occur  with  a  slight  influenza.  After  the  third 
day  from  the  beginning  of  the  symptoms  the  eruption 
comes  out,  and  the  person  thereafter  feels  better  for  a 
time,  or  indeed  does  not  again  feel  sick  at  all.  "There 
is  no  other  eruptive  disease  in  which  such  experience  as 
this  can  be  noted;  it  is  peculiar  to  this  one."       V 

The  distribution  of  the  eruption.  On  the  third  cli 
with  subsidence  of  the  fever,  the  eruption  appears.  It 
appears  first  on  the  face;  later  on  the  back  of  the  hands 
and  wrists. 

In  chickenpox  the  definite  onset  which  character- 
izes smallpox  is  lacking.  The  early  symptoms  in 
chickenpox  are  usually  insignificant,  and  the  fever 
does  not  subside  with  the  appearance  of  the  eruption. 


174        HEALTH  WORK  IN  THE  SCHOOLS 

The  red  spots  (papules)  are  not  so  hard  in  chicken  pox 
as  in  smallpox,  and  they  quickly  form  blisters  (vesicles). 
The  eruption  is  most  abundant  on  the  trunk  and  es- 
pecially on  the  upper  part  of  the  back,  while  the  face  is 
fairly  free. 

Vaccination  affords  almost  perfect  protection  against 
smallpox.  The  literature  on  this  subject  is  so  exhaus- 
tive that  merely  to  mention  the  titles  of  the  most  im- 
portant articles  is  out  of  the  question.  For  a  concise 
and  conclusive  argument,  however,  in  favor  of  vaccina- 
tion, the  reader  may  be  referred  to  Vaccination:  What 
it  is;  What  it  does;  What  its  Claims  are  on  the  People, 
issued  by  the  New  York  State  Department  of  Health. 

Every  individual  ought  to  be  protected  against  small- 
pox by  vaccination,  but  in  any  event  vaccination  must 
be  practiced  at  the  time  of  any  appearance  of  this  dis- 
ease among  school  children. 


CHAPTER   XI 

TRANSMISSIBLE  DISEASES 

(Concluded) 
8.  Tuberculosis 

The  subject  of  tuberculosis  has  been  fully  discussed 
in  the  volume  of  this  series  called  The  Hygiene  of  the 
School  Child,  and  it  is,  therefore,  unnecessary  to  enter 
into  any  extended  details  at  this  point.1 

"Open'*  and  "latent"  tuberculosis,  "Open"  tuber- 
culosis, by  which  is  meant  tuberculosis  in  the  trans- 
missible form,  such  as  is  found  in  unhealed  tuberculous 
conditions  of  the  lungs,  is  rarely  met  by  school  health 
officers  in  their  routine  work.  Evidence  of  former  bone 
tuberculosis  is  seen  not  infrequently  in  the  form  of  de- 
formed spines  (kyphosis)  or  a  shortened  leg,  usually 
caused  by  hip-joint  disease.  Scars  in  the  neck  most 
often  represent  former  tuberculous  lymph-glands  which 
have  either  ruptured  spontaneously  or  have  been 
lanced.  Occasionally  one  observes  discharging  lymph- 
glands  of  tuberculous  nature  in  the  neck  or  the  groin, 
and,  less  often,  abscesses  in  the  back.  Also,  in  relatively 
rare  instances,  cases  of  active  pulmonary  tuberculosis 
are  found.  In  the  main,  however,  tuberculosis  in  school 
children  is  of  the  latent  type,  discoverable  chiefly  by 
use  of  the  Von  Pirquet  test. 

1  See  also  chapter  xiiof  the  present  volume,  "Open- Air  Schools." 


176        HEALTH  WORK  IN  THE  SCHOOLS 

That  a  very  large  number  of  children  are  afflicted 
with  latent  tuberculosis  there  is  no  possible  doubt,  and 
modern  investigations  point  to  the  fact  that  most 
tuberculosis  is  acquired  in  childhood,  even  though  it 
may  not  become  evident  for  many  years.  It  is  the  con- 
viction of  one  of  the  writers,  who  has  personally  exam- 
ined more  than  100,000  school  children,  that  most  of 
the  type  which  we  call  "malnourished'*  are  in  reality 
cases  of  latent  tuberculosis.  This  opinion  is  shared  by 
some  others  who  have  had  wide  experience  in  dealing 
with  children.  For  the  reason  just  stated,  if  for  no 
other,  cases  of  malnutrition  should  receive  prompt  and 
careful  attention. 

Not  nearly  so  many  instances  of  malnutrition  as  we 
imagine  are  really  caused  by  insufficient  food.  If  this 
were  the  fact  fewer  such  cases  would  be  observed 
among  the  children  of  the  well-to-do.  Malnourished 
children  always  greatly  improve  by  treatment  in  open- 
air  schools  where  feeding,  fresh  air,  and  rest  are  skill- 
fully combined.  An  attempt  should  always  be  made  to 
discover  the  nature  of  home  conditions  in  these  cases, 
for  in  some  instances  tuberculosis  will  be  found  present 
in  one  or  more  members  of  the  family. 

One  ought  to  suspect  the  possibility  of  tuberculosis  in 
children  who  show  some  or  all  of  the  following  signs:  — 

Delicate  constitution. 

Tendency  to  tire  out  easily. 

Pallor. 

Flushed  face  at  certain  periods. 

Capricious  appetite. 

Enlarged  cervical  (neck)  glands. 


TRANSMISSIBLE  DISEASES  177 

Adenoids. 
Diseased  tonsils. 

No  delicate  child  should  be  neglected.  The  time  to 
control  tuberculosis  is  at  the  beginning,  when  the  dis- 
ease may  be  indicated  only  by  some  such  general  signs 
as  those  just  mentioned. 

The  teacher's  health  must  receive  attention,  partic- 
ularly in  respect  to  tuberculosis.  One  tuberculous 
teacher  of  careless  or  uncleanly  habits  has  opportunity 
to  infect  the  40  or  50  children  in  her  classroom,  and 
through  them  to  send  infection  into  as  many  homes,  ex- 
posing in  the  end  200  or  300  individuals  to  the  chance 
of  infection.  As  stated  by  Dr.  Langley  Porter,  "when 
we  consider  the  contact  of  child  with  child,  a  contact 
maintained  for  hours  daily,  often  in  an  ill-ventilated 
room,  we  realize  that  the  danger  here  is  very  real.  A 
proper  school  inspection  will  mean  the  elimination  of 
the  actually  tuberculous  pupil  and  teacher  from  con- 
tact with  healthy  pupils  and  instructors." 

Prevention.  To  summarize  the  means  of  preventing 
tuberculosis  in  school  children  we  may  mention  the 
following  essential  points :  — 

(1)  Elimination  of  the  tuberculous  teacher. 

(2)  Segregation  of  the  tuberculous  school  child. 

(3)  Building  up  the  health  of  all   anaemic,  nervous,  and 
weak  school  children. 

(4)  Short  school  day  for  young  children. 

(5)  Well-ventilated  schoolrooms. 

(6)  Sanitary  schoolrooms. 

(7)  Open-air  schools. 

(8)  Low  temperature  schools  (temperature  not  to  exceed 
60°  to  68°  F.). 


178        HEALTH  WORK  IN  THE  SCHOOLS 

(9)  Common-sense  physical  training,  out  of  doors. 

(10)  More  careful  health  observation  on  the  part  of  teachers. 

(11)  Systematic  health  inspection  of  schools. 

(12)  Home  visits  by  nurses. 

(13)  Knowledge  of  the  nature  of  the  food  which  school  chil- 
dren receive. 

(14)  Common-sense,  applicable,  hygiene  instruction. 

9.  Hookworm  Disease 

Hookworm  is  not  often  seen  in  the  school  children  of 
this  country,  except  in  the  Southern  States.  The  dis- 
ease is  also  common  among  the  Japanese,  Hindus, 
Porto  Ricans,  and  in  some  of  the  countries  of  southern 
Europe.  In  the  tropics  the  disease  is  said  to  be  "the 
greatest  enemy  of  the  human  race."  In  the  United 
States  hookworm  has  been  found  common  from  Vir- 
ginia to  Florida  and  Texas.  In  a  few  other  States  it 
has  been  observed  rather  infrequently.  It  is  estimated 
that  at  least  2,000,000  people  of  our  Southern  States 
are  infected. 

Mode  of  transmission.  The  commonest  cause  of  in- 
fection among  school  children  is  the  habit  of  going 
barefooted.  The  disease  commonly  gains  entrance  in 
one  of  two  ways  —  first  and  most  commonly,  through 
the  skin;  second,  and  less  frequently,  through  the 
mouth.  Dock  l  states  that  the  reproductive  stage  is 
reached  only  in  the  intestinal  canal;  that  the  species 
infecting  man  does  not  infect  other  animals;  that  the 
eggs  do  not  hatch  in  the  intestinal  canal;  and  that  the 
larvae  are  not  infectious  until  they  are  at  least  four  or 
five  days  old.  The  real  source  of  infection  is,  therefore, 
1  Dock  and  Bass,  Hookworm  Disease. 


m 


TRANSMISSIBLE  DISEASES  179 

found  in  the  body  wastes  of  individuals  who  are  in- 
fected with  the  disease. 

The  usual  sequence  of  infection  is  as  follows:  The 
eggs  from  the  worms  in  the  human  intestines  reach  the 
soil  with  the  faeces,  often  as  many  as  1,700,000  eggs 
being  passed  in  a  single  stool;  the  eggs  hatch  into  larvae 
in  the  soil;  the  larvae  pass  through  the  skin  (commonly 
through  the  feet)  and  reach  the  intestines;  in  the  intes- 
tines the  larvae  develop  into  adult  worms;  the  adult 
worms  produce  eggs,  which  in  their  turn  are  passed  out 
of  the  body  with  the  faeces. 

The  general  effect  of  the  disease,  when  it  is  severe,  is 
to  produce  an  extreme  degree  of  anaemia,  with  conse- 
quent loss  of  energy  and  mental  alertness.  In  children 
growth  is  interfered  with,  so  that  a  young  man  of  20 
years  who  has  been  infected  since  childhood  is  often  no 
more  developed  than  a  boy  of  12  or  13  years.  In  many 
of  these  cases  of  delayed  development  X-ray  pictures 
of  the  hands  show  the  same  slow  development  of  wrist 
bones  and  the  ends  of  the  long  bones  of  the  arm  as 
that  found  in  cases  of  retarded  development  due  to 
other  causes. 

Prevention.  The  all-important  matter  in  hookworm 
disease  is  prevention.  This  is  best  carried  out  by  the 
following  procedures,  as  given  by  Dock:  — 

(1)  Stopping  the  danger  of  infection  by  exterminat- 
ing the  mature  worms  in  the  bodies  of  human  beings, 
in  order  to  check  the  supply  of  eggs  at  the  source. 

(2)  Preventing  the  growth  or  existence  of  larvae  in 
the  places  where  they  develop. 


180        HEALTH  WORK  IN  THE  SCHOOLS 

(3)  Preventing  infection  by  larvae  that  have  devel- 
oped notwithstanding  the  efforts  mentioned  under 
(1)  and  (2). 

Fortunately  it  has  been  found  an  easy  matter  to 
cure  this  disease,  and,  after  a  preliminary  treatment 
with  "salts,"  a  few  doses  of  thymol  usually  completes 
the  cure. 

10.  Poliomyelitis  (Infantile  Paralysis) 

Little  need  be  said  in  this  book  about  this  disease  of 
childhood,  for  two  reasons :  first,  it  will  rarely  or  never 
be  identified  at  school;  second,  it  fortunately  affects 
children  of  school  age  less  frequently  than  infants. 

Mode  of  transmission.  Evidence  is  now  available 
which  indicates  that  the  disease  may  be  spread  by  the 
stable-fly.  On  the  other  hand,  some  investigations 
throw  considerable  doubt  on  this  point.  At  any  rate, 
the  fly  is  a  menace  to  health,  whether  of  the  stable 
or  domestic  variety,  and  should  be  eliminated  from 
civilized  communities.  The  secretions  of  the  nose  and 
mouth  of  infected  children  carry  the  disease,  a  fact  to 
which  attention  has  been  directed  in  respect  to  most 
contagious  diseases  of  children. 

Control.  There  is  a  division  of  opinion  as  to  whether 
schools  should  be  closed  during  an  epidemic  of  infantile 
paralysis.  Many  modern  hygienists  claim  that  such  a 
procedure  is  quite  unnecessary  and  useless,  while  some 
others  insist  upon  the  prompt  closing  of  the  schools. 
In  any  event,  absolute  isolation  is  necessary.  We  know 
rather  less  about  this  disease  than  any  other  from  which 


TRANSMISSIBLE  DISEASES  181 

children  suffer,  and  it  remains  to-day  one  of  the  mys- 
teries which  medical  science  is  attempting  to  solve, 
but  one  which,  like  most  other  disease  mysteries,  will 
no  doubt  soon  yield  to  painstaking  scientific  investiga- 
tion. 

11.  Epidemic  Meningitis 

As  epidemics  of  meningitis  have  occurred  rather  fre- 
quently in  this  country,  teachers,  nurses,  and  others 
who  deal  with  school  children  ought  to  have  some 
knowledge  of  it.  It  has  been  recognized  in  the  United 
States  since  1805,  and  at  various  periods  since  that 
time  there  have  been  many  definite  epidemics  of  the 
disease. 

According  to  Osier,  epidemic  meningitis  is  most  pre- 
valent in  winter  and  spring.  The  disease  is  primarily 
one  of  childhood,  but  young  adults  are  sometimes 
affected. 

Contagion.  While  epidemic  meningitis  is  distinctly 
transmissible,  it  does  not  spread  in  the  same  manner  as 
does  scarlet  fever  or  measles,  but  more  after  the  man- 
ner of  pneumonia.  In  general  it  may  be  said  that  it  is 
chiefly  communicated  through  the  secretions  of  the 
nose,  mouth,  and  eyes.  The  organism  causing  the  dis- 
ease has  been  known  since  1887. 

Symptoms.  The  attack  in  the  majority  of  cases  is 
sudden.  Sometimes  there  is  abrupt  severe  headache, 
with  fever,  vomiting,  and  a  fast  pulse,  followed  by  rig- 
idity of  the  neck  and  unconsciousness.  Very  acute  at- 
tacks often  begin  with  sudden  dizziness,  followed  by 


182        HEALTH  WORK  IN  THE  SCHOOLS 

vomiting  and  headache,  after  which  fever  occurs,  and 
even  delirium. 

While  there  is  great  variety  in  the  mode  of  onset,  it 
may  be  said  that  in  the  main  the  characteristic  points 
are:  — 

Suddenness  of  attack. 

Headache. 

Dizziness. 

Vomiting. 

Fever. 

Unconsciousness. 

Rapid  pulse. 

Retraction  of  the  head. 

Oscillation  of  the  eyes. 

Sometimes  an  eruption. 

Complications.  Infection  of  the  ear  is  very  common, 
and  deafness  often  follows.  Inflammation  of  various 
joints  (arthritis)  is  common.  Accumulation  of  fluid  in 
the  ventricles  of  the  brain  (hydrocephaly)  sometimes 
results,  causing  permanent  feeble-mindedness. 

Treatment.  Flexner's  serum  is  the  only  form  of  treat- 
ment for  epidemic  meningitis  which  offers  much  hope. 
Every  case  of  this  disease  should  be  diagnosed  early 
and  given  the  Flexner  treatment. 

12.  Contagious  Eye  Diseases  " 

Attention  has  been  called  to  the  fact  that  children  of 
school  age  are  especially  susceptible  to  general  contag- 
ious diseases.  This  is  also  true  of  diseases  affecting  the 

1  In  the  preparation  of  this  section  the  authors  are  indebted  to 
Whitaker  and  Ray-Wiggin  Company  for  permission  to  use  certain 
material  from  Dr.  Hoag's  The  Health  Index  of  Children. 


TRANSMISSIBLE  DISEASES  183 

eyes.  The  early  recognition  of  these  eye  troubles  is  of 
very  great  importance,  not  only  to  the  child  afflicted, 
but  also  to  his  intimate  associates. 

As  a  rule,  a  teacher  is  justified  in  excluding  any 
child,  or  at  least  in  insisting  upon  a  certificate  from  a 
physician,  whenever  such  child  is  found  with  evidence 
of  discharging  eyes,  gluing  of  the  eyelids,  or  reddening 
of  their  inner  surfaces,  accompanied  with  any  marked 
sensitiveness  to  light.  To  assist  the  teacher,  parent,  or 
any  one  else  who  has  not  had  the  medical  experience, 
to  distinguish  the  different  contagious  diseases  of  the 
eye,  the  following  brief  description  of  their  essential 
characteristics  may  prove  useful. 

(a)  Pink-eye  (acute  catarrhal  conjunctivitis) 

This  disease  is  of  frequent  occurrence  among  chil- 
dren, and  spreads  in  a  school  rapidly.  It  is  commonly 
carried  by  means  of  the  common  wash-basin,  or  towel, 
borrowed  handkerchiefs,  and  the  like.  The  child  com- 
plains of  smarting  eyes,  sensitiveness  to  light,  and  a 
sensation  as  though  sand  were  in  the  eyes.  The  eyelids 
stick  together  at  night,  and  there  is  often  some  visible 
discharge  in  the  corners  of  the  eyes  between  the  lids. 
The  small  blood  vessels  in  the  white  part  of  the  eyes 
(sclera)  and  of  the  lining  of  the  lids  (conjunctiva)  are 
very  prominent.  This  results  in  very  noticeable  red- 
dening of  the  eyes. 

The  disorder  usually  lasts  from  ten  to  fourteen  days, 
but  it  may  persist  a  much  longer  time.  The  trouble  is 
easily  cured  if  it  is  attended  to  at  once. 


184        HEALTH  WORK  IN  THE  SCHOOLS 

(b)  Gonorrhoea!  conjunctivitis 

This  serious  disease  of  the  eyes  is  often  found  in  new- 
born children,  but  it  may  also  occur  in  children  of  any 
age  or  in  adults.  It  is  caused  by  the  germ  of  gonorrhoea. 
Indications  of  this  disease  are:  — 

Intense  inflammation  of  the  eyelids. 
Profuse,  thick,  purulent  discharge. 
Lids  red  and  swollen. 
Usually  intense  pain. 
Marked  aversion  to  light. 
Profuse  flow  of  tears. 

This  form  of  eye  disease  is  most  serious  in  its  conse- 
quences, often  causing  blindness.  It  is  highly  contag- 
ious. For  these  reasons  it  ought  to  be  recognized  early, 
and  receive  immediate  and  skillful  treatment.  Fortu- 
nately, it  is  not  extremely  frequent  among  school  chil- 
dren. The  disease  usually  lasts  from  four  to  six  weeks, 
but  sometimes  very  much  longer.  The  child  must  be 
kept  carefully  away  from  other  children,  and  every 
precaution  used  to  prevent  contagion  by  means  of  tow- 
els, handkerchiefs,  wash-basins,  the  fingers,  etc. 

(c)  Diphtheritic  conjunctivitis 

This  disease  is  due  to  the  same  germ  as  that  which 
produces  diphtheria  in  the  throat  or  nose.  It  is  very 
dangerous,  but  rather  infrequent.  Contagion  is  very 
easy,  and  therefore  its  early  recognition  is  of  the  ut- 
most importance.  The  essential  characteristics  of  this 
disease  are:  — 


TRANSMISSIBLE  DISEASES  185 

Severe  pain  in  the  eyes. 

Eyelids  tense  and  dark-colored. 

Discharge  at  first  thin  and  scanty,  later  thick  and  puru- 
lent. 

A  thick,  tenacious,  grayish  membrane  forms  upon  the 
inner  surface  of  the  eyelids  which  is  very  difficult  to  remove. 

The  disease  demands  the  same  treatment  as  diph- 
theria of  the  throat,  and  the  periods  of  exclusion  and 
quarantine  are  of  great  importance. 

(d)  Trachoma 

This  is  one  of  the  most  serious  of  all  diseases  of  the 
eyes,  being  highly  destructive  and  extremely  likely  to 
produce  blindness.  Trachoma  is  prevalent  in  certain 
foreign  countries,  especially  in  the  Orient.  In  Califor- 
nia trachoma  is  most  frequently  found  among  Indians 
and  Mexicans,  sometimes,  also,  among  the  Japanese. 
It  is  extremely  common  among  the  Indians  of  Minne- 
sota. In  the  large  cities  of  the  East  and  Middle  West 
the  disease  often  occurs  among  the  children  of  other 
nationalities,  largely  in  the  slums  or  poorer  districts. 
As  many  as  17,000  cases  have  been  discovered  in  the 
New  York  schools  in  one  year. 

Children  suffering  from  the  disease  must  be  imme- 
diately isolated,  and  kept  so  until  recovery  is  complete. 
The  principal  characteristics  of  trachoma  are:  — 

Inflammation.  This  is  not  very  intense,  but  there  is  con- 
siderable swelling  of  the  lids,  an  aversion  to  light,  and  flow- 
ing of  tears. 

The  outer  surface  of  the  eyeball  becomes  roughened. 

The  inner  surface  of  the  eyelids  becomes  covered  with 


186        HEALTH  WORK  IN  THE  SCHOOLS 

small  granules,  not  unlike  boiled  sago  grains  in  appearance, 
and  this  produces  what  is  called  granular  eyelids. 

The  disease  is  extremely  contagious  through  the  dis- 
charge from  the  eyes.  Towels,  basins,  handkerchiefs, 
etc.,  are  the  chief  means  of  conveyance,  but  uncleanly 
habits,  unhygienic  surroundings,  poor  food,  poverty, 
and  the  like,  favor  its  development  and  spread.  Strict 
quarantine  against  this  malady  must  be  established, 
and  continued  until  all  signs  of  discharge  have  ceased. 
Laboratory  examinations  should  be  made  in  all  cases  of 
suspected  trachoma. 

Conclusions 

(1)  All  contagious  eye  diseases  need  to  be  recognized 
early. 

(2)  Removal  from  school  of  children  with  such  diseases 
is  necessary. 

(3)  Great  care  must  be  exercised  to  prevent  contagion 
through  — 

The  common  towel; 
The  common  basin; 
Handkerchiefs; 
Dirty  fingers; 
Bedclothing; 

Public  bathing-suits,  and,  possibly,  swimming- 
tanks. 


TRANSMISSIBLE  DISEASES  187 

13.   Contagious  Diseases  of  the  Skin1 

(a)  Scabies  (the  itch) 

A  contagious  skin  disease,  due  to  an  animal  para- 
site which  burrows  in  the  skin,  causing  intense  itching 
and  scratching.  The  disease  usually  begins  upon  the 
hands  and  arms,  spreading  over  the  whole  body,  but 
does  not  affect  the  face  and  scalp.  Between  the  fingers, 
on  the  front  of  the  wrist,  at  the  bend  of  the  elbows  and 
near  the  arm-pits  are  favorite  locations  for  the  disease; 
but  in  persons  of  cleanly  habits  the  disease  may  not 
show  at  all  upon  the  hands,  and  its  real  nature  is  deter- 
mined only  after  a  most  thorough  and  careful  examina- 
tion. There  is  great  variation  in  the  extent  and  sever- 
ity of  this  disease,  lack  of  personal  care  and  cleanliness 
always  favoring  its  development.  Scratching  soon 
brings  about  an  infection  of  the  skin  with  some  of  the 
pus-producing  germs,  and  the  disease  is  then  accom- 
panied by  impetigo,  a  pus  infection  of  the  skin. 

Itch  is  very  common,  and,  because  of  the  great  vari- 
ation in  its  severity,  mild  cases  are  often  mistaken  for 
hives,  eczema,  etc.  All  children  who  are  scratching  or 
have  an  irritation  upon  the  skin  should  be  examined 
for  scabies. 

It  is  very  important  that  all  infected  members  of  a 
family  be  treated  till  cured,  else  the  disease  is  passed 
back  and  forth  from  one  to  another.  It  is  also  impor- 

1  With  acknowledgments  to  a  pamphlet  on  Medical  Inspection  by 
the  Massachusetts  Board  of  Education,  and  one  by  the  Cincinnati 
City  Board  of  Health,  called  Suggestions  to  Teachers. 


188        HEALTH  WORK  IN  THE  SCHOOLS 

tant  that  all  underclothing,  bedding,  towels,  and  other 
things  that  come  in  contact  with  the  body,  be  boiled 
when  washed.  All  cases  of  scabies  should  be  excluded 
from  school  until  cured. 

(b)  Pediculi  capitis  (head  lice) 

An  extremely  common  accident  among  children, 
either  from  wearing  each  others'  hats  and  caps,  or 
hanging  them  on  each  others'  pegs,  or  from  combs 
and  brushes.  No  person  should  be  blamed  for  having 
lice  —  only  for  keeping  them. 

The  irritation  caused  by  vermin  in  the  scalp  leads  to 
scratching,  which  in  turn  causes  an  inflammation  of 
the  skin  of  the  neck  and  scalp.  The  skin  then  easily  be- 
comes infected  with  some  of  the  pus-producing  germs, 
and  large  or  small  scabs  and  crusts  are  formed  with  the 
dried  matter  and  blood.  Along  with  this  condition  the 
glands  back  of  the  ears  and  in  the  neck  become  swollen, 
and  may  be  very  painful  and  tender. 

The  condition  of  pediculosis  is  most  easily  detected 
by  looking  for  the  eggs  (nits),  which  are  fastened  to  the 
hair  and  are  not  readily  brushed  off.  The  condition  is 
best  treated  by  killing  the  living  parasites  with  crude 
petroleum,  and  then  getting  rid  of  the  nits.  With  boys, 
this  is  easy  —  a  close  hair-cut  is  all  that  is  needed; 
with  girls,  by  using  a  fine-toothed  comb  wet  in  alcohol 
or  vinegar,  which  dissolves  the  attachment  of  the  eggs 
to  the  hair.  All  combs  and  brushes  must  be  carefully 
cleansed. 

The  best  way  to  eradicate  lice  from  a  school  is  to 


TRANSMISSIBLE  DISEASES  189 

have  the  school  nurses  give  the  necessary  treatments. 
This  can  be  done  at  school,  without  any  exclusions.  If 
there  are  no  school  nurses,  then  children  with  pedicu- 
losis should  be  excluded  from  school  until  the  heads 
are  clean.  In  Massachusetts,  parents  who  neglect  or 
refuse  to  care  for  their  children  in  this  respect  may  be 
prosecuted  under  the  compulsory  attendance  law. 

(c)  Ringworm 

A  parasitic  disease  of  the  skin  and  scalp.  When  it 
occurs  upon  the  skin  it  yields  readily  to  treatment;  but 
upon  the  scalp  it  is  extremely  chronic.  Ringworm  of 
the  skin  usually  appears  on  the  face,  hands,  or  arms  — 
rarely  upon  the  body  —  in  rings  of  varying  size.  One 
or  more,  usually  not  widely  separated,  may  be  present 
at  the  same  time.  All  ringed  eruptions  upon  the  skin 
should  be  examined  for  ringworm. 

When  the  disease  attacks  the  scalp,  the  hairs  fall 
or  break  off  near  the  scalp,  leaving  dime-to-dollar- 
sized  areas,  nearly  bald.  The  scalp  in  these  areas  is 
usually  dry  and  somewhat  scaly,  but  may  be  swollen 
and  crusted.  The  disease  spreads  at  the  circumfer- 
ence of  the  area  and  new  areas  arise  from  scratching, 
etc. 

Another  disease,  somewhat  like  ringworm  of  the 
scalp,  is  known  as  "favus"  —  a  disease  much  more 
common  in  Europe  than  America.  In  this  disease  quite 
abundant  crusts  of  a  yellowish  color  are  present 
where  the  process  is  active.  The  roots  of  the  hairs 
are  killed,  so  that  the  loss  of  the  hair  from  this  disease 


190        HEALTH  WORK  IN  THE  SCHOOLS 

is  permanent,  a  scar  remaining  when  the  condition 
is  cured. 

Care  must  be  taken  to  see  that  all  combs  and  brushes 
are  thoroughly  cleansed,  and  to  prevent  children  wear- 
ing each  others'  hats,  caps,  etc.  Children  with  ring- 
worm of  the  skin  may  be  treated  at  school  by  school 
nurses.  Ringworm  of  the  scalp  was  formerly  dealt  with 
by  exclusion,  or  by  segregation  of  the  children  in  special 
classes.  By  the  earlier  tedious  methods  of  treatment 
attendance  at  the  "ringworm  class"  was  sometimes 
necessary  for  many  months,  or  even  years.  The  new 
X-ray  method  is  so  much  more  expeditious  that  where 
this  method  is  used  the  disease  no  longer  presents  any 
serious  problem. 

(d)  Impetigo 

A  disease  characterized  by  a  few  or  many,  large  or 
small,  flat  or  elevated,  pustules  or  festers  upon  the  skin. 
The  condition  is  often  secondary  to  irritation  or  itch- 
ing diseases  of  the  skin  (hives,  lice,  itch),  and  scratch- 
ing starts  up  a  pus  infection. 

The  disease  most  often  appears  upon  the  face,  neck, 
and  hands;  less  often  upon  the  body  and  scalp.  The 
size  of  the  spots  varies  very  much,  and  they  often  run 
together  to  form  on  the  face  large  superficial  sores,  cov- 
ered with  thick,  dirty,  yellowish,  or  brown  crusts.  The 
disease  is  contagious,  and  often  spread  by  towels  and 
things  handled.  Children  having  impetigo  should  not 
be  allowed  to  attend  school  until  all  sores  are  healed 
and  the  skin  is  smooth. 


TRANSMISSIBLE  DISEASES  191 

General  Summary 

Any  of  the  following  points  ought  to  suggest  the  pos- 
sibility of  some  form  of  transmissible  disease  in  chil- 
dren: — 

Flushed  face.  Persistent  cough. 

Lassitude.  Scratching. 

Vomiting.  Sore  throat. 

Eruption.  Aches  and  pains. 

Red  eyes.  Headache. 

Watery  eyes.  Fever. 

Nasal  discharge.  Loss  of  appetite. 


192      TABLE  V.    COMMON  TRANSMISSIBLE 


s 


I 

I 


Principal  early  signs  and  symptoms 


Begins  like  cold  in  the  head,  with 
feverishness,  running  nose,  in- 
flamed and  watery  eyes,  and 
sneezing;  small  crescented  groups 
of  mulberry-tinted  spots  appear 
about  the  third  day;  rash  seen 
first  on  forehead  and  face.  The 
rash  varies  with  heat;  may  almost 
disappear  if  the  air  is  cold,  and 
come  out  again  with  warmth. 

Illness  usually  slight.  Onset  sud- 
den. Rash  often  first  thing  no- 
ticed; no  cold  in  head.  Usually 
have  feverishness  and  sore  throat, 
and  the  eyes  may  be  inflamed. 
Rash  something  between  measles 
and  scarlet  fever;  variable. 

Sometimes  begins  with  feverish- 
ness, but  is  usually  very  mild  and 
without  sign  of  fever.  Rash  ap- 
pears on  second  day  as  small 
pimples,  which  in  about  a  day  be- 
come filled  with  clear  fluid.  This 
fluid  then  becomes  matter,  the 
spot  dries  up,  and  the  crust  falls 
off.  May  have  successive  crops 
of  rash  until  tenth  day. 

The  onset  is  usually  sudden,  with 
headache,  languor,  feverishness, 
sore  throat,  and  often  the  child  is 
sick  at  the  stomach.  Usually 
within  twenty-four  hours  the 
rash  appears,  and  is  finely  spot- 
ted, evenly  diffused,  and  bright 
red.  The  rash  is  seen  first  on  the 
neck  and  upper  part  of  the  chest, 
and  lasts  three  to  ten  days,  when 
it  fades  and  the  skin  peels  in 
scales,  flakes,  or  even  large  pieces. 
The  tongue  becomes  whitish, 
with  bright  red  spots.  The  eyes 
are  not  watery  or  congested. 


Method  of  Infection 


Forced  exhalation  and 
discharges  from  nose 
and  mouth. 


Forced  exhalation  and 
discharges  from  nose 
and  mouth. 


Forced  exhalation  and 
crusts  on  the  spots. 


Forced  exhalation, 
and  discharges  from 
nose  and  mouth,  par- 
ticles of  skin,  and  dis- 
charges from  supurat- 
ing  glands  or  ears. 
Milk  especially  apt 
to  convey  infection. 


DISEASES  OF  SCHOOL   CHILDREN 


Remarks 


Period  of  exclusion  recom- 
mended 


After  effects  often  severe.  Period  of 
greatest  risk  of  infection,  first  three  or 
four  days,  before  the  rash  appears. 
May  have  repeated  attacks.  Great  va- 
riation in  type  of  disease.    Often  fatal. 


After  effects  slight. 


When  children  return,  examine  head  for 
overlooked  spots.  All  spots  should  have 
disappeared  before  child  returns.  A 
mild  disease  and  seldom  any  after  effects. 


Dangerous  both  during  attack  and  from 
after  effects.  Great  variation  in  type 
of  disease.  Slight  attacks  as  infectious 
as  severe  ones.  Many  mild  cases  not 
diagnosed  and  many  concealed.  The 
peeling  may  last  six  to  eight  weeks.  A 
second  attack  is  rare.  When  scarlet 
fever  is  occurring  in  a  school,  all  cases 
of  sore  throat  should  be  sent  home. 


Four  to  five  weeks. 


Three  weeks. 


Till  all  scabs  have  dis- 
appeared. 


Six  to  eight  weeks,  or 
until  desquamation 
has  ceased. 


»  With  acknowledgments  to  The  Health  Index  of  Children  (Hoag). 


194      COMMON  TRANSMISSIBLE  DISEASES 


Principal  early  signs  and  symptoms 


Method  of  infection 


•a 

3 


a 

a 
3 


Onset  insidious;  may  be  rapid  or 
gradual.  Typically  sore  throat, 
great  weakness,  and  swelling  of 
glands  in  the  neck,  about  the 
angle  of  the  jaw.  The  back  of  the 
throat,  tonsils,  or  palate  may 
show  patches  like  pieces  of  yel- 
lowish-white kid.  The  most  pro- 
nounced symptom  is  great  debil- 
ity and  lassitude,  and  there  may 
be  little  else  noticeable.  There 
may  be  hardly  any  symptoms  at 
all. 

Begins  like  cold  in  the  head,  with 
bronchitis  and  sore  throat,  and  is 
a  cough  which  is  worse  at  night. 
Symptoms  may  at  first  be  very 
mild.  Characteristic  "  whooping  " 
cough  develops  in  about  a  fort- 
night, and  the  spasm  of  cough- 
ing often  ends  with  vomiting. 

Onset  may  be  sudden,  beginning 
with  sickness  and  fever  and  pain 
about  the  angle  of  the  jaw.  The 
glands  become  swollen  and  tender 
and  the  jaws  stiff,  and  the  saliva 
sticky. 

Begins  with  feverishness,  pain  in 
head,  back,  and  limbs,  and  usu- 
ally cold  in  the  head. 

Illness  is  usually  well  marked  and 
the  onset  rather  sudden,  with 
feverishness,  severe  backache, 
and  sickness.  About  third  day  a 
red  rash  of  shot-like  pimples,  felt 
below  the  skin  and  seen  first 
about  the  face  and  wrists.  Spots 
develop  in  two  days,  then  form 
little  blisters,  and  in  another  two 
days  become  yellowish  and  filled 
with  matter.  Scabs  then  form, 
and  these  fall  off  about  the  four- 
teenth day. 


Forced  exhalation  and 
discharges  from  nose, 
mouth,  and  ears. 


Forced  exhalation  and 
discharges  from  nose 
and  mouth. 


Forced  exhalation  and 
discharges  from  the 
nose  and  mouth. 


Forced  exhalation  and 
discharges  from  the 
nose  and  mouth. 


Forced  exhalation;  all 
discharges,  and  parti- 
cles of  skin  or  scabs. 


OF  SCHOOL  CHILDREN.—  Continued         195 


Remarks 


Very  dangerous  both  during  attack  and 
from  after  effects.  When  diphtheria  is 
occurring  in  a  school,  all  children  suffer- 
ing from  sore  throat  should  be  excluded. 
There  is  great  variation  of  type,  and 
mild  cases  are  often  not  recognized,  but 
are  as  infectious  as  severe  cases.  There 
is  no  immunity  from  further  attacks. 
Membrane  may  occur  in  nose  only. 


After  effects  often  very  severe,  and  the 
disease  causes  great  debility.  Relapses 
are  apt  to  occur.  Second  attacks  rare. 
Specially  infectious  for  first  week  or 
two.  If  a  child  is  sick  after  a  bout  of 
coughing,  it  is  most  probably  suffering 
from  whooping-cough.  Great  variation 
in  type  of  disease. 


Seldom  leaves  after  effects.    Very  infec- 
tious. 


Excessively  infectious.  After  effects  often 
very  serious  and  accompanied  with  pros- 
tration and  nervous  disability. 

Is  peculiarly  infectious.  When  small- 
pox occurs  in  connection  with  a  school 
or  with  any  of  the  children's  homes,  an 
endeavor  should  be  made  to  have  all  per- 
sons over  seven  years  of  age  vaccinated. 
Cases  of  modified  smallpox  —  in  vaccin- 
ated persons  —  may  be,  and  often  are, 
so  slight  as  to  escape  detection.  Fact 
of  existence  of  disease  may  be  concealed. 
Mild  or  modified  smallpox  as  infectious 
as  severe  type. 


Period  of  exclusion  recom- 
mended 


Six  weeks,  or  until  all 
diphtheritic  germs 
have  disappeared 
from  cultures  taken 
from  throat. 


Two  months,  or  until 
cough  and  vomiting 


About  a  month. 


About  three  weeks. 


Till  all  scabs  have  dis- 
appeared. 


196        HEALTH  WORK  IN  THE  SCHOOLS 

SELECTED  REFERENCES 

(Chapters  ix,  x,  and  xi) 

1.  Bernhard,  Dr.  L. : "  Zur  Diphtheriebekampf ung  in  den  Schulen." 
Beiheft  with  Zt.  f.  Schulges.,  August,  1912,  pp.  198-207. 

2.  Bridge,  Dr.  Norman:  Tuberculosis.  1912, 

*  3.  Burgerstein  u.  Netolitzsky:  Handbuch  der  Schulhygiene.   1912, 

pp.  421-62. 
4.  Carruthers,  Dr.  A.:  "Epidemic  Poliomyeletis  in  West  Suffolk." 
School  Hygiene,  1912,  pp.  94-101. 

*  5.  Chapin,  Dr.  C.  V.:  Sources  and  Modes  of  Infection.   1910,  pp. 

399. 

*  6.  Cohn,  Dr.  M.:  "Schulschluss  u.  Morbiditat  an  Masern,  Schar- 

lach  u.  Diphtheric"   Zt.  f.  Schulges.,  1913,  pp.  64  ff. 

*  7.  Cornell,  Dr.  Walter  S.:  The  Health  and  Medical  Inspection  of 

School  Children,  1912,  pp.  524-64. 

8.  D'Ewart,  John:  "School  Infectivity."    The  Child,  1912,  pp. 
162-67. 

9.  Dock  and  Bass:  The  Hookworm  Disease. 

10.  Dregalski,  Dr.  V.:  "Bekampfung  der  iibertragbaren  Krank- 
heiten  in  den  Schulen."  Beiheft  with  Zt.  f.  Schulges.,  August, 
1912,  pp.  739-48. 

11.  Eberstaller,  Dr.:  "Masern.u.  Schule."  Inter.  Mag.  Sch.  Hyg., 
vol.  in,  1907,  pp.  1-20. 

*12.  Fairfield,  Dr.  Letitia:  "School  Influence  on  the  Mortality  from 

Scarlet  Fever,  Diphtheria  and  Measles."  School  Hygiene,  1911, 

pp.  549-53. 
*13.  Gilmour,  A.:  "Measles  and  Child  Welfare."    The  Child,  1913, 

pp.  352-60. 
*14.  Gulick  and  Ayres:  The  Medical  Inspection  of  Schools.    1913. 

(2d  edition.) 

15.  Harmon,  N.  Bishop:  "Concerning Dirt."  School  Hygiene,  1910. 
pp.  74-81. 

16.  Herrman,  Charles:  "Prevention  of  the  Spread  of  Contagious 
Disease  in  Public  Schools."  Inter.  Mag.  Sch.  Hyg.,  1909,  pp. 
1-16. 

17.  Hill,  Dr.  Charles:  The  New  Public  Health.  Minn.  St.  Board  of 
Health. 

*18.  Hoag,  Dr.  E.  B.:  The  Health  Index  of  Children.  1910.  (Chapter 

19.  Hoag  and  Hall:  Bulletin  of  American  Academy  of  Medicine, 
1911. 

20.  Hogarth,  Dr.  A.  H.:  The  Medical  Inspection  of  Schools.  1909. 
(Chapter  xiii.) 

21.  Hopf,  Dr.:  "Hygienische  Bedeutung  des  Handewaschens." 
Zt.f.  Schulges.,  1906,  pp.  154/. 

22.  Hutchinson,  Dr.  Woods:  Preventable  Diseases.  1909.  (Chapters 
x  and  xi.) 


TRANSMISSIBLE  DISEASES  197 

23.  Jacobi,  Dr.  A.:  "Contagious  Disease."  Report  of  Fifth  Congress 

of  Am.  Sch.  Hyg.  Assoc,  1911,  pp.  51-58. 
*24.  Kerr,  Dr.  James:  (and  others):  "The  Control  of  Measles." 

School  Hygiene,  1913,  pp.  131-69. 
25.  Laser,    Dr.:    "Das   Nagelbeissen   der   Schulkinder."     Zt.  f. 

Schulges.,  1906,  pp.  219/. 
*26.  Matheny,  W.  A.:  "The  Common  Drinking-Cup."   Ped.  Sem., 

1911,  pp.   205-14.     (Contains   bibliography   of  twenty-three 

titles.) 
27.  Meylan,  G. :  "  The  Hygiene  and  Sanitation  of  Summer  Camps." 

Report  of  Sixth  Congress  of  Am.  Sch.  Hyg.  Assoc,  1912,  pp.  71- 

76. 
*28.  Nice,  Leonard  B.:  "The  Disinfection  of  Books."    Ped.  Sem.t 

1911,  pp.  198-204.    (Contains  bibliography.) 
*29.  Oker-Blom,  Dr.  Max:  "Zur  Bekampfung  des  Scharlachs  in  den 

Schulen."  Inter.  Mag.  Sch.  Hyg.,  1912,  pp.  516-28. 

30.  Osier:  Modern  Medicine  Series. 

31.  Petruschky,  Dr.  J.:  "Der  Diphtherieschutz  der  Schulkinder." 
Beiheft  with  Zt.  f.  Schulges.,  August,  1912,  pp.  177-88. 

32.  Porter,  Dr.  Charles:  School  Hygiene  and  the  Laws  of  Healtht 
pp.  224-38. 

33.  Pottenger,  Dr.  F.  M.:  Tuberculosis. 

*34.  Poelschau,  Dr.:  "Leber  die  Bekampfung  der  Masern  durch  die 
Schule."  Beiheft  with  Zt.f.  Schulges.,  August,  1912,  pp.  162-77. 
35.  Porter,  Dr.  Langley:  Prevention  of  Tuberculosis  in  Children. 

*36.  Rosenfeld,  Dr.  S.:  "  Schulbesuchsdauer  u.  Morbiditat."  Zt.  f. 
Schulges.,  1906,  pp.  472/. 

*37.  Schulz,  Dr.:  "Ueber  Klassenepidemien  von  Diphtheric" 
Beiheft  with  Zt.  f.  Schulges.,  August,  1912,  pp.  188-98. 

38.  Sequeira,  Dr.  J.  H.:  "The  Treatment  of  Ringworm."   School 
Hygiene,  1912,  pp.  155-61. 

39.  Shaw,  E.  R.:  School  Hygiene.   1901.    (Chapter  xn.) 

*40.  Von  Sholly,  Dr.  Anna:  "Trachoma;  Its  Prevalence  and  Treat- 
ment."  Report  of  Sixth  Congress  Am.  Sch.  Hyg.  Assoc,  1912, 
pp.  115-24. 
41.  Toledano,  Dr.:  "La  revaccination  des  enfants  des  ecoles."  La 
Midecine  Scolaire,  1912,  pp.  113-25,  and  162-76. 

*42.  Williams,  Dr.  Lewis:  "The  Control  of  Contagious  Diseases 
through  the  School  Clinic."   School  Hygiene,  May,  1910. 

*43.  Newmayer,  S.  W.:  Medical  and  Sanitary  Inspection  of  Schools. 
1914,  pp.  318. 

See  also  the  Proceedings  of  the  various  International  Congresses 
of  School  Hygiene,  especially  of  1913. 


CHAPTER  XII 

OPEN-AIR  SCHOOLS 

Recent  spread 

The  phenomenal  spread  of  open-air  schools  during 
the  last  few  years  constitutes  one  of  the  most  signif- 
icant developments  in  modern  education.1  The  first 
open-air  recovery  school  was  that  of  Charlottenburg, 
Germany,  in  1904.  England's  first  school  of  this  type 
was  opened  in  1907;  America's  first,  in  1908.  Since 
then,  open-air  schools  for  tuberculous  or  pre-tuber- 
culous  children  have  been  established  in  nearly  all  of 
the  large  cities  of  every  country.  There  were  open-air 
schools  in  forty -four  cities  of  the  United  States  in  1912. 
No  city  which  has  undertaken  the  work  has  subse- 
quently abandoned  it. 

The  school  department  of  Boston  has  adopted  the 
plan  of  building  one  or  more  open-air  classrooms  in 
each  new  school  building  to  be  erected.  About  5  per 
cent  of  Boston's  school  population  will  attend  these 
classes.  In  some  of  the  cities  and  countries  of  Cali- 
fornia a  majority  of  the  school  buildings  now  being 
erected  are  constructed  on  a  plan  which  permits  all 
the  rooms  to  be  converted  in  a  moment  into  open-air 
rooms.    This  is  done  by  means  of  hinged  windows, 

1  For  a  comprehensive  and  interesting  account  of  this  entire  move- 
ment, including  data  regarding  management,  cost,  etc.,  the  reader  is 
referred  to  the  admirable  booklet  by  Leonard  P.  Ayres. 


OPEN-AIR  SCHOOLS  199 

which  reach  from  floor  to  ceiling,  and  which  occupy 
practically  all  of  the  space  of  one  or  more  of  the  walls. 
The  open-air  school  has  been  conducted  in  the  main 
for  the  benefit  of  tuberculous  or  pre-tuberculous  chil- 
dren. Here  such  children  are  watched  over  by  school 
nurses  or  medical  attendants,  fed  from  one  to  five 
meals  of  nourishing  food  per  day,  and  given  a  daily 
program  which  resembles  very  little  the  study  pro- 
gram of  the  ordinary  school.  The  book  work  is  usually 
reduced  to  two  or  three  hours  per  day  and  the  re- 
mainder of  the  time  is  devoted  to  manual  work,  play, 
meals,  rest,  and  sleep. 

Program 

The  following  program  of  the  Bradford  (England) 
open-air  school  is  typical :  — 


9  A.M. 

Breakfast. 

9.45  to  10.45 

Ordinary  school  work. 

10.45  to  11 

Play. 

11  to  12 

Ordinary  school  work. 

12.30  to  1 

Dinner. 

1  to  2  P.M. 

.  Rest  and  sleep. 

2  to  3 

Play. 

3  to  4.30 

Outdoor  lessons  (nature  study. 

geography,  etc.). 

5 

Tea. 

5.30  to  6 

Play. 

In  some  of  the  open-air  schools  of  Germany  as  many 
as  five  meals  are  served  per  day;  in  the  United  States, 
more  often  from  one  to  three.  In  some  cases  the  amount 
of  time  devoted  to  instruction  is  less  than  that  at  Brad- 
ford, and  the  period  for  sleep  proportionately  longer. 


200        HEALTH  WORK  IN  THE  SCHOOLS 

Results 

Tuberculous  children  who  attend  open-air  classes 
seldom  fail  to  show  immediate  and  rapid  improvement 
in  weight,  appetite,  blood-count,  mental  alertness, 
and  freedom  from  colds.  At  the  Bostall  Wood  School 
(London),  children  gained  on  the  average  six  and  a 


Lbs 

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Oct. 

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FIG.  6 

Showing  the  average  weekly  gain  or  loss  in  weight  of  children  attending  the 
Bradford  Open- Air  School  in  1908.  The  dotted  line  shows  the  average  in- 
crease which  takes  place  in  the  case  of  children  under  ordinary  conditions. 


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Mid- winter  sun-baths  at  Leysin  Hospital  for  children  with  tuberculosis  of  the  bone. 


Pivot  windows.    Open-Air  School.    George  Bancroft  Building,  Minneapolis. 
OPEN-AIR  SCHOOLS 


OPEN-AIR  SCHOOLS  201 

half  pounds  during  the  thirteen  weeks  the  school  was 
in  session.  The  Charlottenburg  school  brought  a 
similar  increase  in  weight.  In  the  first  open-air  school 
of  Chicago  the  average  gain  per  child  was  three  and 
three  quarter  pounds  during  the  first  month.  These 
gains  are  all  much  in  excess  of  the  normal. 

As  a  rule,  the  rapid  gain  in  weight  continues  only 
so  long  as  the  school  is  in  session.  When  vacation 
comes,  and  the  child  is  thrown  back  upon  the  resources 
and  regimen  of  the  home,  his  progress  toward  recovery 
is  checked  or  thwarted  altogether.  In  the  school  year 
1910-11,  the  children  of  Open-Air  School  Number  21, 
New  York  City,  lost  during  the  Thanksgiving,  Christ- 
mas, and  Easter  vacations  an  average  of  1.72  pounds 
per  child.  This  was  49  per  cent  of  the  average  gain 
per  child  during  the  entire  year.  In  one  of  the  Cleve- 
land open-air  schools  (1910-11)  the  pupils  made  an 
average  gain  in  weight  of  more  than  four  and  a  half 
pounds  between  December  12  and  January  9,  while 
the  pupils  of  a  similar  school,  in  the  same  city,  required 
to  be  indoors  during  the  same  period  on  account  of 
building  repairs,  suffered  an  average  loss  of  one  and 
a  half  pounds,  notwithstanding  the  continuance  of 
special  feeding. 

The  improvement  in  the  condition  of  the  blood  is 
also  very  marked.  Children  who  are  placed  in  open-air 
classes  are  usually  found  to  have  a  haemoglobin  con- 
tent of  about  70  per  cent.  Sometimes  it  is  as  low  as 
50  or  60  per  cent.  Under  the  combined  influence  of 
outdoor  instruction,  feeding,   decreased  book-work, 


202        HEALTH  WORK  IN  THE  SCHOOLS 

and  increase  of  rest  and  play,  the  haemoglobin  seldom 
fails  to  mount  rapidly  to  80  or  85  per  cent.  This  is 
within  5  or  10  per  cent  of  normal  for  children  of  school 
age.  At  Bradford  the  average  increase  of  haemoglobin 
during  nine  weeks  was  10  per  cent.  For  Open-Air 
School  Number  21,  New  York  City,  the  average  gain 
per  child  from  October  to  May  was  13.75  per  cent. 

Haemoglobin  records,  like  those  of  weight,  demon- 
strate the  superiority  of  the  open-air  school  over  the 
average  city  home.  This  is  clearly  revealed  in  figure  7. 


n 
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80 

78 

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Haemoglobin  tests,  Providence  Open-Air  School,  1908-1900.    Average  for 
class.    Note  falling  off  during  vacation. 


OPEN-AIR  SCHOOLS 


203 


Except  for  vacation  disturbances,  therefore,  the 
haemoglobin  improves  under  the  open-air  regimen 
throughout  the  school  year.  The  gain  is  usually  very 
rapid  at  first,  then  becomes  somewhat  slower  as  the 
normal  condition  is  approached. 

It  is  interesting  to  compare  with  this  the  haemoglobin 
curve  of  normal  children  in  the  ordinary  indoor  class. 
Such  a  comparison  was  made  in  New  York  City,  in 
1910-11,  between  27  normal  children  of  the  regular 


90 
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Oct. 

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Apr. 

May 

June 

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Curves  Bhowing  changes  in  haemoglobin  during  school  year  in  anaemic  chil- 
dren of  Open-Air  School  No.  21,  New  York,  and  in  normal  children 
chosen  from  an  ordinary  class. 


204        HEALTH  WORK  IN  THE  SCHOOLS 

class  and  the  21  sickly  children  of  Open-Air  School 
Number  21.  The  blood  of  normal  children  in  the  ordi- 
nary class  was  found  to  deteriorate  gradually  during 
the  school  year,  while  that  of  the  open-air  children 
significantly  improved. 

In  a  seaside  hospital  in  Germany,  conducted  as  a 
six-weeks'  summer-vacation  colony  for  tuberculous 
children,  Haberlin  *  has  for  several  years  made  blood 
tests  of  children  on  arrival  and  on  departure.  The 
average  gain  of  81  pupils,  4  to  14  years  of  age,  was 
452,000  red  corpuscles  per  cubic  millimeter  of  blood. 
The  average  gain  in  white  corpuscles  was  2000. 
Haemoglobin  tests  for  362  children  gave  an  average 
increase  of  about  8  per  cent.  Twenty-eight  children 
who  were  studied  separately  had  an  average  haemo- 
globin content  of  79  per  cent  on  arrival  in  June,  92 
per  cent  on  their  departure  after  six  weeks,  86  per 
cent  the  following  December,  and  84  per  cent  in 
February.  Nineteen  of  the  children  were  followed  for 
two  years.  When  these  first  entered  the  colony  the 
haemoglobin  averaged  75  per  cent.  In  six  weeks  it 
rose  to  88  per  cent,  and  was  85  per  cent  when  the 
pupils  returned  to  the  colony  the  following  summer. 
This  is  important  as  showing  that  much  of  the  good 
accomplished  is  a  permanent  gain. 

Haberlin  found  for  913  such  children  an  average 

gain  in  chest  circumference  of  1.6  centimeters  during 

the  six  weeks,  and  an  average  increase  of  7.5  kilograms 

in  strength  of  grip.   The  gain  in  weight  was  several 

1  See  reference  10  at  end  of  this  chapter. 


OPEN-AIR  SCHOOLS  205 

times  the  normal,  and  in  the  case  of  74  per  cent  of  the 
children  was  permanent.  Many  of  these  children,  says 
Haberlin,  are  from  good  homes.  Notwithstanding 
this,  they  are  barely  able,  after  their  return  home,  to 
retain  the  advantage  gained  in  the  six  weeks'  summer 
colony.  No  further  gain  is  made.  But  the  same  chil- 
dren, on  their  return  to  the  colony  the  following  sum- 
mer, immediately  begin  to  gain  at  several  times  the 
normal  rate. 

Appetite  and  sleep  improve  correspondingly.  When 
Open- Air  School  Number  21  of  New  York  began  work 
in  September,  1910,  no  child  ate  more  than  his  regular 
allotment  of  food,  and  20  per  cent  did  not  eat  all  that 
was  served  them.  Within  eight  weeks  all  were  eating 
their  entire  allotment,  and  25  per  cent  of  them  were 
given  a  second  helping.  Sleep,  which  averaged  for 
the  first  month  only  12  minutes  during  the  daily 
rest-hour,  increased  to  41  minutes  by  the  end  of  the 
year. 

After  a  few  months  in  the  open-air  school  a  large 
proportion  of  tuberculous  children  (usually  from  one 
third  to  one  half)  present  the  appearance  of  complete 
recovery,  while  most  of  the  remainder  show  distinct 
improvement.  Neither  improvement  nor  apparent 
cure,  however,  justifies  the  return  of  the  child  to  the 
indoor  class.  Relapse  may  occur.  The  mere  fact  that 
a  tubercular  tendency  exists  gives  such  a  child  an 
undeniable  right  to  that  type  of  school  which  will  ac- 
complish most  to  strengthen  his  physical  defenses. 


206        HEALTH  WORK  IN  THE  SCHOOLS 

Pedagogical  results 

The  mental  results  of  the  open-air  school  are  hardly- 
less  important  than  the  physical.  Children  who  are 
listless,  apathetic,  and  retarded  may  become  interested 
and  attentive.  Nervous  children  develop  habits  of 
self-control.  Incorrigible  children  become  docile  and 
helpful.  The  spirit  of  the  open-air' school  is  "  differ- 
ent." Freedom,  initiative,  and  social  cooperation  re- 
place the  artificiality  and  routine  of  the  usual  school. 
Open-air  schools  tend  to  inculcate  open-air  morals. 

One  of  the  best  lessons  of  all  relates  to  pedagogical 
economy.  The  open-air  school  has  demonstrated  that 
it  is  possible  for  sickly  children  to  make  as  satisfactory 
school  progress  on  a  study  program  of  three  hours  per 
day  as  healthy  children  ordinarily  make  on  a  five-hour 
program.  In  the  New  York  school  already  referred 
to,  48  per  cent  of  the  pupils  advanced  at  more  than 
the  normal  rate.  Grades  in  the  open-air  classes  usually- 
average  better  than  in  others.  Attendance  is  nearly 
always  more  regular.  It  is  not  necessary  for  the  child 
to  become  retarded  while  recovering  from  tuberculosis. 

The  instruction,  itself,  in  open-air  classes  has  note- 
worthy advantages.  The  child  is  brought  into  closer 
relation  with  the  world  of  animate  and  inanimate 
things  around  him,  and  is  more  likely  to  associate  the 
knowledge  gained  in  class  with  his  own  experiences. 
Arithmetic,  for  instance,  is  taught  in  the  Charlotten- 
burg  school  by  measuring  objects,  counting  trees, 
calculating  spaces,  etc.   In  the  geography  classes  re- 


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Complete  relaxation  on  the  cots. 
CHICAGO   OPEN-AIR  CLASSES 


OPEN-AIR  SCHOOLS  207 

lief  maps  are  constructed  in  the  sand  showing  the 
configuration  of  the  surrounding  country.  The  action 
of  running  water,  the  formation  of  deltas,  the  causes 
of  floods,  the  modes  of  irrigation,  etc.,  are  all  made 
clear  by  objective  instruction.  The  habits  of  plants 
and  animals,  fundamental  facts  relating  to  the  de- 
composition of  rocks,  soil  formation,  weather  condi- 
tions, etc.,  are  easily  imparted  and  made  intimate 
possessions  of  the  child's  mind. 

Open-air  schools  have  so  fully  proved  their  superi- 
ority as  to  warrant  their  extension  to  include  a  con- 
siderable proportion  of  the  school  population.  At  least 
ten  or  fifteen  per  cent  should  be  looked  upon  as  def- 
initely predisposed  to  tuberculosis.  Nor  is  there  any 
valid  argument  for  limiting  the  advantages  of  open- 
air  schools  to  children  who  are  sickly.  Schools  which 
accomplish  so  much  for  the  latter  could  not  fail  to  be 
of  benefit  to  normal  children.  It  is  foolish  to  deny  a 
healthful  environment  to  all  except  those  whose 
health  is  already  impaired. 

REFERENCES  ON  OPEN-AIR  SCHOOLS 

1.  Austin,  Gertrude:  "Heliotherapy  for  Tuberculous  Children." 

The  Child,  1912,  pp.  839-45. 
*2.  Ayres,  Leonard  P.:  Open- Air  Schools.   1910,  pp.  171. 

3.  Baginsky,   Adolph:   "Ueber  Waldschulen   u.   Walderholung- 
statten."  Zt.f.  pad.  Psych.,  Path.,  u.  Hygiene,  1906,  pp.  101-77. 

4.  Bienstock:  "Die  Waldschule  in  Muhlhausen."  Zt.f.Schulges., 
1908,  pp.  219  ff. 

*5.  Bruner,  F.  G.:  "The  Influence  of  Open  Air  and  Low  Tempera- 
ture on  the  Mental  Alertness  and  Scholarship  of  Pupils."  Proc. 
N.E.A.,  1911,  pp.  890-98. 
6.  Clark,  Ida:  "Open- Air  Schools  in  England  and  Germany." 
Kgn.  Rev.,  1910,  pp.  462-69. 


208        HEALTH  WORK  IN  THE  SCHOOLS 

7.  Crowley,  Ralph:  The  Hygiene  of  School  Life.   1910.    (Chapter 

XIV.) 

*8.  Curtis,  Elnora:  "Outdoor  Schools."    Ped.  Sem.,  1909,  pp.  169- 

94. 
9.  Godfring:  "Die  Waldschule  f.  Schwachbefahigte  Kinder."  Zt. 
f.  Schulges.,  1907,  pp.  236/. 
*10.  Haberlin,  Dr.:  "Die  Blutarmut  u.  Skrofulose  der  Kinder;  ihre 
Folgen  u.  ihre  Behandlung."  Zt.f.  Kinderforsch.,  1911,  pp.  1-8. 
11.  Henderson,  C.  H.,  "Outdoor  Schools."*  The  World's  Work, 
January,  1909. 
*12.  Kingsley,  Sherman  C:  Open- Air  Crusaders.   1911,  pp.  109. 
*13.  De  Montmorency,  J.  E.:  "School  Excursions  and  Vacation 
Schools."    Special  Rept.  by  London  Board  of  Education,  1907, 
pp.  71. 

14.  Spencer,  Mrs.  Anna:    "Open- Air  Schools."    Rept.  of  Inter. 
Cong,  of  Tuberculosis,  1908,  pp.  612-18. 

15.  Taylor,  D.  M.:  "Residential  Open- Air  Schools  for  Delicate 
children."   The  Child,  1912,  pp.  846-54. 

16.  Warner,  Allan:  "Open- Air  Schools  by  the  seaside."  The  Child, 
1912,  pp.  826-38. 

*17.  Watt:  W.  E.:  Open  Air.  1910,  pp.  282. 
18.  Williams,  Ralph:  "The  Sheffield  Open- Air  Recovery  School." 
School  Hygiene,  1910,  pp.  136-43. 


CHAPTER  XIII 

SCHOOL  HOUSEKEEPING 

School  dust  and  its  dangers 

Schoolrooms  have  too  long  been  prisons  for  the 
incarceration  of  children  and  dust.  Until  recently,  a 
school  without  its  eternal  cloud  of  dust  was  as  in- 
conceivable as  a  school  without  children.  However, 
with  the  advance  of  physiological  and  bacteriological 
science  our  ideals  are  undergoing  a  rapid  change,  and 
the  modern  canons  of  school  hygiene  are  ever  becom- 
ing more  strict  in  regard  to  methods  of  insuring  clean- 
liness. 

School  cleanliness  means  chiefly  the  avoidance  of 
dust.  To  carry  on  a  constant  warfare  against  this 
enemy  of  children  we  employ  janitor  service  amount- 
ing to  the  full  time  of  30,000  or  40,000  men  and  women. 
Their  monthly  wages  amount  to  more  than  the  wages 
paid  to  our  standing  army.  The  enemy  they  fight 
is  infinitely  more  menacing  to  our  national  welfare 
than  the  military  forces  of  other  nations.  Directly 
and  indirectly,  dust  probably  causes  greater  destruc- 
tion of  life  in  the  United  States  every  year  than  was 
accomplished  by  battle  in  any  year  of  our  Civil  War. 
All  nations  employ  naval  and  military  experts  at  liberal 
salaries  to  study  scientifically  the  means  of  defense 
and  destruction  in  order  that  the  forces  of  war  may 


210        HEALTH  WORK  IN  THE  SCHOOLS 

be  managed  effectively.  But  nations  do  not  employ 
dust  experts.  Few  people  know  what  constitutes 
efficient  janitor  service,  or  care  enough  about  it  to 
find  out.  Would  not  a  national  training  school  for 
janitors  contribute  more  to  humanity  than  do  mili- 
tary and  naval  academies? 

Dust  is  of  two  kinds,  organic  and  inorganic.  Dust 
of  some  kind  is  omnipresent.  On  lofty  mountain-tops 
or  over  the  sea  the  number  of  dust  particles  per  cubic 
centimeter  of  air  may  be  as  low  as  150  or  200.  In  a 
garden  near  the  center  of  Paris  the  number  was  160,000 
per  cubic  centimeter.  The  air  in  a  room  where  the 
Royal  Scientific  Society  of  Edinburgh  mef  was  found 
to  contain  275,000  particles  per  cubic  centimeter  be- 
fore the  meeting  and  400,000  after  an  hour  and  a  half. 
Near  the  ceiling  there  were  3,000,000  particles  per 
cubic  centimeter. 

But  not  all  dust  is  injurious.  If  not  metallic  or 
gritty,  inorganic  dust  particles  may  be  breathed  in 
great  numbers  without  injury.  Apart  from  germ- 
bearing  particles,  it  is  the  gritty  mineral  dust  that  is 
most  to  be  feared.  Mineral  dust  produces  its  injury 
in  two  ways:  (1)  Numerous  small  particles  lodge  in  the 
lungs  and  excite  by  their  presence  the  formation 
around  them  of  a  fibrous  tissue  which  replaces  the 
true  lung  tissue;  and  (2)  they  produce  lacerations  of 
the  throat  and  lungs  which  serve  as  lodging-places 
for  disease  germs,  especially  the  tubercle  bacilli. 
Laborers  who  grind  pottery,  and  inhale  thousands  of 
sharp-edge  dust  particles  with  every  breath,  die  with 


SCHOOL  HOUSEKEEPING  211 

six  times  the  normal  frequency  from  tuberculosis. 
For  the  same  reason,  glass-workers  and  stone-cutters 
have  a  mortality  from  tuberculosis  several  times  the 
normal. 

Mineral  dust  is  abundant  in  all  but  the  best-kept 
schoolrooms.  It  is  (1)  blown  in  by  the  dust-laden  air 
from  streets  or  roads;  (2)  carried  in  on  the  shoes  of 
children  as  dirt  and  gravel,  later  to  be  ground  and 
pulverized  on  the  floor;  and  (3)  manufactured  in  large 
quantities  by  the  inordinate  use  of  chalk  and  black- 
boards. Dust  from  all  these  sources  is  so  dangerous 
that  relentless  warfare  should  be  waged  against  it. 

Organic  dust  is  dangerous  principally  as  a  germ- 
carrier,  although  air-borne  germs  do  not  play  as  great 
a  role  in  causing  infectious  diseases  as  they  were 
formerly  thought  to  play.  Nevertheless  infections 
sometimes  occur  in  this  way,  and  hygiene  demands 
that  we  should  keep  the  number  of  organic  dust  parti- 
cles as  low  as  possible. 

The  amount  of  germ-carrying  dust  in  a  room  is 
tested  by  exposing  to  the  air,  for  a  given  time,  a  gela- 
tin plate  of  standard  size  and  material,  which  catches 
the  floating  germs  and  acts  as  a  culture  medium  for 
the  development  of  bacterial  colonies.  The  plate  is 
then  examined  microscopically,  and  the  number  of 
bacterial  colonies  counted. 

The  number  collected  on  a  plate  is  found  to  vary 
from  none  in  purest  mountain  air  to  many  hundreds 
in  the  worst  ventilated  dwellings,  shops,  and  schools. 
In  a  children's  drawing-room  the  number  in  a  short 


212        HEALTH  WORK  IN  THE  SCHOOLS 

time  was  multiplied  eight  times  by  the  dancing  of 
twenty  children.  In  railway  coaches,  bedrooms, 
schools,  etc.,  the  number  increases  rapidly  the  more 
persons  there  are  crowded  together,  the  more  actively 
they  move  about,  and  the  smaller  the  intake  of  pure 
air. 

The  investigations  of  Carnelly,  Haldane,  and  Ander- 
son show  that  the  number  of  germs  carried  by  school- 
room air  averages  about  ten  times  as  great  in  the 
worst  ventilated  as  in  the  best  ventilated  schools. 
Children  are  often  exposed  for  six  hours  a  day  to  an 
atmosphere  which  is  five  times  as  thick  with  germs 
as  the  ordinary  bedroom  in  a  middle-class  home.  It 
was  found  that  the  number  of  bacteria  per  liter  of  air 
in  a  Dundee  high  school  could  be  raised  from  10  to 
150,  by  having  the  pupils  stamp  on  the  floor.  The 
number  is  always  enormously  increased  by  calisthenic 
exercises  in  the  room,  by  the  movements  of  children 
at  recess,  and  by  dry  sweeping.  Even  a  well- ventilated 
schoolroom,  if  dirty,  has  been  found  to  contain  more 
bacterial  colonies  than  a  one-room  city  dwelling,  kept 
clean. 

Prevention  of  dust  by  means  of  floor  oils 

Many  experimental  tests  have  demonstrated  that 
floor  oils  are  extremely  effective,  if  applied  correctly 
and  often  enough.  The  floor  should  first  be  cleaned 
thoroughly,  the  oil  should  be  spread  thin,  and  after 
drying  the  unabsorbed  oil  should  be  mopped  up. 
Treatment  should  be  given  at  least  three  days  before 


SCHOOL  HOUSEKEEPING 


213 


the  room  is  to  be  used,  and  should  be  repeated  at  least 
two  or  three  times  yearly. 

The  following  table  from  Dr.  Lambert,1  which  is  a 
fair  sample  of  numerous  experiments  of  this  kind, 
illustrates  very  well  the  effect  of  floor  oil  on  the  num- 
ber of  germs  in  schoolroom  air:  — 

TABLE  VI 


Colonies  of  bacteria 

Plates  exposed 

Floors 
treated 
with  oil 

Floors 

not 

treated 

5  minutes  in  still  air 

0 

2 
38 
11 

6 

1 

7 

30  minutes  in  still  air 

12 

5  minutes  during  sweeping 

456 

5  minutes  just  after  sweeping 

79 

5  minutes  beginning  10  minutes  after  sweeping 
5  minutes  beginning  15  minutes  after  sweeping 

62 
31 

Dr.  Butler's  tests  (quoted  by  Lambert)  show  that 
the  bacteria  are  no  more  numerous  over  an  oiled  floor 
after  four  weeks  than  over  an  untreated  floor  two  days 
after  scrubbing.  In  fact,  the  oil  is  very  effective  for 
twelve  to  fifteen  weeks  after  its  application.  Other 
tests  have  shown  that  an  old,  worn  floor  is  more  hy- 
gienic when  oiled  than  a  new  and  well-laid  floor  un- 
treated. Oker-Blom  has  demonstrated  that  if  a  floor 
is  properly  treated  with  oil  the  amount  of  dust  in  the 
air  after  sweeping  is  less  than  is  the  case  after  the  chil- 
dren have  been  permitted  to  run  twice  around  the 
room  in  physical  exercises.2 

1  See  reference  10  at  the  end  of  this  chapter. 

2  See  reference  12  at  the  end  of  this  chapter. 


214        HEALTH  WORK  IN  THE  SCHOOLS 

Against  the  use  of  oil  it  has  been  argued  that  it 
darkens  the  floors,  makes  them  slippery,  and  causes 
the  soiling  of  girls'  dresses.  These  arguments  have 
little  weight.  The  darkening  can  be  partly  prevented 
by  properly  cleaning  the  floors  before  the  oil  is  applied, 
and  by  wiping  them  every  week  with  wet  cloths.  The 
floors  will  not  be  made  slippery  if  the  excess  of  oil  is 
removed,  nor  will  they,  after  the  first  few  days,  spot 
the  dress  very  considerably.  With  the  shorter  dresses 
now  worn,  the  skirt  and  the  floor  seldom  come  in  con- 
tact. Pupils  should  be  taught,  anyway,  that  it  is 
better  and  cleaner  to  have  a  little  dirt  on  the  dress 
than  to  mix  it  with  the  food  which  is  given  to  the 
lungs. 

Method  of  cleaning 

The  number  of  dust  particles  and  germs  also  depends 
on  the  method  of  dirt  removal.  The  least  effective 
method  is  that  of  sweeping  the  dry  floor  with  the  old- 
fashioned  straw  broom.  Only  the  coarse  dirt,  which, 
of  course,  is  harmless  because  it  could  not  reach  the 
lungs,  is  removed  in  this  way.  The  fine  dirt,  the  only 
kind  that  can  injure  us,  is  mixed  with  the  air.  The 
bristle  brush  far  excels  the  broom  as  an  instrument  of 
cleanliness,  and  is  especially  effective  when  used  with 
dampened  sawdust  or  other  materials  of  like  nature. 
Still  better  is  the  oil  brush,  an  ordinary  brush  furn- 
ished with  a  small  tank  for  kerosene.  The  kerosene 
slowly  feeds  down  from  the  tank  upon  the  bristles, 
keeping  them  slightly  moist.   When  the  floor  is  kept 


SCHOOL  HOUSEKEEPING  215 

well  oiled  and  brushes  of  this  type  are  used,  the  dust 
practically  disappears. 

It  seems  probable,  however,  that  vacuum  cleaners 
are  destined  to  supersede  all  other  methods  in  the 
care  of  schoolhouses,  as  they  have  done  for  office 
buildings,  hotels,  apartment  houses,  etc.  Some  hun- 
dreds of  school  buildings  are  already  equipped  with 
them,  with  a  resulting  noticeable  decrease  in  sickness 
and  improvement  of  attendance. 

Where  primitive  methods  of  sweeping  are  employed, 
dusting  becomes  an  important  feature  in  the  care  of 
the  school  building.  The  feather  duster  and  the  old- 
fashioned  broom  were  fit  companions  in  crime.  Both 
have  been  driven  from  our  city  schools,  but  both 
continue  their  nefarious  business  in  the  rural  dis- 
tricts. They  should  be  outlawed  relentlessly.  The 
feather  duster  moves  the  dust,  but  does  not  re- 
move it.  The  only  way  to  get  rid  of  the  dust 
which  settles  on  the  school  furniture  is  to  wipe  it 
up  with  a  damp  cloth.  No  other  dusting  deserves 
the  name,  and  any  other  kind  is  worse  than  none 
at  all. 

Other  ways  of  preventing  dust 

We  have  already  seen  that  floating  dust  is  many 
times  increased  by  the  marching,  stamping,  and  play 
of  children  in  the  room.  Calisthenic  exercises  should 
be  given  out  of  doors,  and,  except  when  it  cannot  be 
avoided,  children  should  not  be  permitted  to  remain 
indoors  at  recess  time.    Open  windows  let  the  fresh 


216        HEALTH  WORK  IN  THE  SCHOOLS 

air  blow  in  and  the  dust  blow  out.  The  windows 
should  be  kept  open  during  all  recesses. 

As  a  rule,  blackboards  are  used  much  more  than  is 
necessary.  "Dustless"  crayons  are  not  quite  dustless, 
but  should  replace  the  soft  plaster-of-Paris  chalks 
still  so  generally  used.  Better  than  chalk  and  black- 
board is  the  "  muroscroll, "  a  paper  surface  which  rolls 
in  a  wooden  frame  and  is  used  with  wax  crayon.  It 
is  inexpensive,  convenient,  and  while  not  rendering 
the  blackboard  entirely  unnecessary,  it  can  replace  it 
for  most  purposes. 

Dust  can  be  further  prevented  by  proper  cleanliness 
of  the  children  in  shoes,  dress,  and  body.  The  schools 
should  be  provided  with  doormats  of  both  the  wire 
and  fiber  varieties. 

Special  effort  should  be  made  to  keep  the  gym- 
nasium clean.  Children  breathe  more  deeply  there 
than  in  the  classroom.  Mats  and  other  dust-gathering 
paraphernalia  should  be  discarded.  The  windows 
should  be  kept  open,  and  cleaning  should  be  thorough 
and  frequent. 

If  the  school  building  employs  mechanical  ventila- 
tion, care  should  be  exercised  to  keep  the  fresh-air 
supply  free  from  dust.  The  intake  should  not  be  near 
a  street  or  a  dusty  playground.  In  many  cases  it  is 
necessary  to  screen  the  air  at  the  intake  by  letting  it 
pass  through  a  cloth  filter,  which  is  kept  damp  by  the 
dropping  of  water  upon  it. 

The  basement  also  deserves  special  mention,  partic- 
ularly when  it  is  used  as  a  substitute  for  playgrounds. 


j 

1 

1                                                                   1 

1                                                                    1 

■>•.- 

THE  MUROSCROLL 


SCHOOL  HOUSEKEEPING 


217 


It  is  almost  always  poorly  ventilated,  and  is  usually 
filled  with  fine  mineral  dust  produced  by  the  move- 
ment of  children  over  the  cement  floors.  If  a  real  play- 
ground is  impossible,  it  is  often  better  to  use  the  halls 
than  the  basement  for  this  purpose.  Chicago  has  re- 
cently abolished  basement  play,  and  other  cities  are 
rapidly  following  the  example.  The  moral  argument 
against  the  basement  playground  is  as  strong  as  the 
hygienic. 

Standards  of  cleanliness 

The  low  standard  of  cleanliness  still  prevailing  in 
the  care  of  the  school  is  well  brought  out  in  an  in- 
vestigation by  the  Russell  Sage  Foundation  in  1911. 
By  means  of  a  questionnaire  sent  to  our  1200  cities, 
reports  were  secured  from  758  on  this  point.  The  main 
results  are  summarized  in  the  table  given  below.    It 

TABLE   VII 


Frequency 


Cities  reporting 

Floors 

Floors 

Windows 

washed 

swept 

washed 

1 

574 

1 

1 

49 

1 

3 

86 

0 

36 

6 

22 

27 

2 

8 

8 

0 

5 

135 

2 

117 

50 

1 

84 

140 

0 

139 

115 

2 

111 

57 

0 

31 

68 

10 

139 

44 

0 

5 

Daily 

Once  in  2  days 
Once  in  three  days. 

Weekly 

Once  in  2  weeks . . . 
Once  in  3  weeks . . . 

Monthly 

Once  in  2  months. . 
Once  in  3  months. . 
Once  in  5  months. . 

Once  a  year 

As  needed 

Never 


218        HEALTH  WORK  IN  THE  SCHOOLS 

will  be  noted  that  less  than  one  half  wash  the  floors 
as  often  as  once  in  three  months,  and  that  nearly 
10  per  cent  do  not  sweep  oftener  than  once  in 
three  days.  It  is  very  probable  that  if  data  could 
be  secured  from  the  cities  which  failed  to  answer 
the  questionnaire  the  figures  would  be  still  more 
shocking. 

The  school  cannot  be  kept  sanitary  unless  it  is 
thoroughly  swept  and  dusted  each  school  day.  The 
sweeping  should  always  be  done  with  windows  open 
and  after  the  close  of  the  school  day.  The  dusting 
should  be  done  in  the  morning,  at  least  half  an  hour 
before  the  pupils  assemble.  If  the  floors  have  not  been 
oil-dressed,  damp  sawdust  or  some  other  preparation 
should  be  used  in  sweeping.  Untreated  floors  should 
be  varnished  once  a  year,  and  all  cracks  should  be 
kept  filled.  In  addition,  the  floors  and  all  the  furniture 
need  to  be  thoroughly  washed  every  few  weeks.  Win- 
dows also  should  be  cleaned  several  times  a  year,  to 
keep  them  more  transparent. 

Copenhagen  requires  that  the  school  furniture  be 
washed  at  least  once  every  fourteen  days,  the  windows 
eight  times  a  year,  and  the  inside  of  the  desks  once  a 
year.  The  floors  must  be  cleaned  daily,  and  dry 
sweeping  and  dry  dusting  are  prohibited.  These 
measures  were  instituted  chiefly  for  the  purpose  of 
combating  tuberculosis. 

Janitor  service  should  not  ordinarily  be  done  by  the 
pupils,  but  in  case  this  cannot  be  avoided,  only  pupils 
of  good  physical  constitution,  and  those  who  come 


SCHOOL  HOUSEKEEPING  219 

from  families  untainted  with  tuberculosis,  should  be 
permitted  to  do  the  work. 

Professional  training  for  janitors 

Efficient  housekeeping  in  the  school  should  be  sub- 
stituted for  our  present  haphazard  janitor  service. 
The  school  should  be  kept  as  clean  as  our  best  hospitals. 
Before  this  can  be  brought  about,  janitors  will  have 
to  be  better  trained  for  the  work  they  have  to  do. 
Too  often  janitors  have  nothing  to  recommend  them 
except  "poverty  or  political  pull."  The  position  of 
janitor  is  really  a  responsible  one.  No  other  individ- 
ual about  the  school  building,  unless  it  be  the  princi- 
pal, has  so  much  influence  over  conditions  which 
affect  the  health  of  the  pupils. 

At  present  even  the  better  class  of  janitors  usually 
do  this  work  by  rule-of-thumb  methods.  This  is  be- 
cause they  have  received  no  instruction  as  regards 
the  scientific  principles  which  relate  to  their  work. 
Instead  of  merely  being  able  to  operate  a  fan,  etc., 
mechanically,  the  janitor  ought  to  know  why  fresh 
air  is  needed.  He  should  not  only  be  willing  to  sweep 
and  dust  according  to  rules,  but  he  should  appreciate 
the  dangers  arising  from  bad  methods  of  school 
housekeeping.  He  should  not  only  be  able  to  run  the 
ventilating  and  heating  apparatus  when  it  is  in  order; 
he  should  also  have  the  mechanical  skill  to  make 
certain  repairs  and  to  locate  defects. 

Such  knowledge  and  skill  do  not  come  of  themselves. 
Professional  training  courses  are  needed,  along  the 


220        HEALTH  WORK  IN  THE  SCHOOLS 

lines  suggested  by  references  6,  8,  and  13  at  the  end 
of  this  chapter.  Courses  of  this  type  do  not  cost  much 
in  time  or  money,  and  the  results  are  out  of  all  pro- 
portion to  either.  It  is  vain  to  expect  in  janitors  a  love 
of  cleanliness  or  a  conscientious  adherence  to  the  rules 
laid  down  for  them,  if  they  do  not  appreciate  the  dan- 
gers of  uncleanliness  and  the  reasonableness  of  the 
rules.1 

REFERENCES 

*1.  Ayres,  Leonard  P.:  "What  American  Cities  are  doing  for  the 
Health  of  School  Children."  Annals  Am.  Acad.  Polit.  and  Soc. 
Sci.,  March,  1911. 

*2.  Burgerstein,  Leo:  "The  Main  Problems  of  Schoolroom  Sanita- 
tion and  School  Work."  Ped.  Sent.,  1910,  pp.  15-28. 

3.  Burrage  and  Bailey:  School  Sanitation  and  Decoration.   1899. 

4.  Burmeister,  K. :  "  Ueber  die  Verwendung  von  Staubbindenden 
Fussbodenolen  in  Schulen."  Inter.  Mag.  Sch.  Hyg.,  1905,  pp. 
185-217. 

5.  Cooley,  R.  L.:  "The  Vacuum  Cleaning  of  Schoolhouses  a  Spe- 
cial Problem."  Am.  Sch.  Board  J.,  July,  1911,  pp.  18-19. 

*6.  Dresslar,  F.  B.:  School  Hygiene,  1913,  pp.  344-63. 

7.  Engels,  Dr.:  "Staubbindende  Fussbodenole."  Zt.  f.  Schulges., 
1903,  pp.  349-72. 

8.  Frost,  W.  D.:  "Our  Short  Course  for  Janitors."  Proc.  N.E.A., 
1911,  pp.  990-92. 

9.  Furst,  M.:  "Ueber  die  Reinigung  der  Volkschulklassen."  Zt. 
f.  Schulges.,  1903,  pp.  441-47  and  545-67. 

*10.  Lambert,  John:  "Preparations  for  the  Prevention  of  Dust  in 

Schools."    The  Child.,  January,  1912,  pp.  279-89. 
•11.  Macfie,  R.  G.:  Air  and  Health.   1909,  pp.  161-91. 
12.  Oker-Blom,  Max:  "Durfen  die  Schulkinder  beim  Kehren  der 

Schulraume  behilflich  sein?"    Inter.  Mag.  Sch.  Hyg.,  1912,  pp. 

477-90. 
*13.  Putnam,  Dr.  Helen:  School  Janitors,  Mothers,  and  Health.  1913, 

pp.  201. 

1  See  reference  6  for  an  ideal  set  of  instructions  for  the  use  of 
janitors. 


CHAPTER  XIV 

THE  TEACHING  OF  HYGIENE:  THE  FIRST  SIX  GRADES 

Inculcating  health  habits 

Those  who  are  interested  in  the  subject  of  hy- 
giene and  sanitation  in  schools,  whether  as  students, 
teachers,  or  principals,  ought  to  possess  some  def- 
inite knowledge  of  the  fundamental  ideas  underly- 
ing the  successful  presentation  of  health  principles 
to  children.  These  principles  of  health  are  in  fact 
relatively  simple,  but  unfortunately  almost  no  other 
subject  in  the  public  schools  is  so  inadequately  taught 
as  hygiene.  This  condition  is  to  be  explained  in  part 
by  the  fact  that  teachers  are  themselves  ordinarily 
poorly  instructed  in  the  subject;  in  part  by  the  fact 
that  the  subject-matter  is  not  directly  applied  to  the 
real  life  of  the  pupil,  and  is  therefore  ineffective. 

There  is  a  vast  difference  between  instructing  a 
child  about  principles  pertaining  to  his  health  and 
inducing  him  to  put  such  principles  into  action.  The 
teacher's  problem  is  mainly  the  latter  one,  and  any 
method  of  instruction  which  fails  in  this  respect  is  a 
failure  altogether. 

We  hear  much  about  the  health  supervision  of 
schools,  physical  education,  and  the  like,  but  how 
often  are  these  ideas  associated  with  the  proper 
methods  of  school  sanitation  and  with  efficient  instruc- 


222        HEALTH  WORK  IN  THE  SCHOOLS 

tion  of  pupils  in  matters  pertaining  to  personal  health? 
The  truth  is  that  the  various  health  problems  in 
schools  have  not  been  sufficiently  correlated,  and 
therefore  much  waste  of  time  and  energy  have  re- 
sulted. 

The  problems  of  school  hygiene  will  never  be  solved 
in  a  satisfactory  manner  until  the  closely  related 
factors  entering  into  them  are  clearly  apprehended 
and  properly  associated.  Of  these  factors,  that  of 
hygiene  teaching  is  one  of  the  most  fundamental. 
How  shall  health  instruction  be  made  efficient  in  the 
different  grades,  and  to  pupils  of  various  ages  and  of 
different  home  conditions?  It  would  seem  self-evi- 
dent that  the  first  requirement  is  that  the  instruction 
must  be  adapted  to  the  pupil's  powers  of  compre- 
hension, but  this  is  the  very  requirement  most  often 
lost  sight  of.  The  adaptation  of  the  subject-matter 
to  the  intellectual  and  social  development  of  the  child 
has  been  strangely,  and  one  might  almost  say  per- 
versely, neglected.  Miniaturing  a  subject  adapted 
to  an  adult  mind  does  not  necessarily  bring  it  within 
the  range  of  the  child's  comprehension. 

In  the  lowest  grades,  say  from  the  first  to  the  fifth 
\  inclusive,  little  formal  instruction  is  necessary,  but 
health  habits  must  be  established  at  this  stage  of 
the  child's  development.  This  can  be  successfully 
accomplished  by  regarding  such  habits  as  an  im- 
portant part  of  the  child's  everyday  life  at  school, 
and  as  far  as  possible  in  the  home.  From  the  time  a 
■  child  enters  school,  until  he  is  about  ten  or  eleven 


THE  TEACHING  OF  HYGIENE  223 

years  of  age,  it  is  a  mistake  to  suppose  that  he  is  much 
influenced  by  explanations  and  reasons.  His  habits 
of  life  during  this  period  ought  to  be  largely  auto- 
matic. Children  of  this  age  who  learn  successfully 
do  so  mostly  by  imitation  and  constant  repetition. 

This  is  the  age  during  which  environment  exerts 
its  greatest  influence,  for  the  young  child  becomes  a 
part  of  all  that  surrounds  him.  A  child's  character 
in  most  fundamental  particulars  is  usually  pretty  well 
established  by  the  time  he  is  seven  or  eight  years  of 
age,  if  indeed  not  earlier.  It  is  of  the  utmost  impor- 
tance, therefore,  to  place  young  children  in  a  proper 
health  environment.  This  must  find  expression  in 
the  schoolroom,  in  the  personal  habits  of  the  teacher 
herself,  in  the  school  associates  of  the  child,  and  in 
the  general  conditions  of  the  child's  home. 

The  rather  common  practice  of  attempting  to  in- 
struct very  young  pupils  in  such  subjects  as  the 
effects  of  narcotics  and  stimulants,  the  physiological 
uses  of  food,  the  structure  of  the  body,  the  functions 
of  organs,  the  chemistry  of  the  air,  the  nature  of  the 
blood,  the  growth  of  bacteria,  and  the  methods  by 
which  they  are  spread,  and  the  like,  is  so  absurd  as 
to  seem  past  belief.  Yet  these  are  some  of  the  many 
topics  to  be  found  mentioned  in  most  courses  of  study 
for  children  in  the  lower  grades,  and  in  part  required 
by  the  laws  of  the  State.  The  young  child's  mind 
never  fully  grasps  such  abstract  ideas.  Information 
at  this  period,  to  be  of  value,  must  be  concrete,  def- 
inite, capable  of  being  expressed  at  once  in  action,  and 


224        HEALTH  WORK  IN  THE  SCHOOLS 

stated  in  terms  with  which  the  boy  or  girl  is  already 
perfectly  familiar.  The  child  must  be  instructed  how 
to  do  the  right  thing  in  health,  rather  than  why  to  do 
( it,  just  as  the  aim  of  moral  education  is  to  train  us  to 
do  the  right  thing  at  the  right  moment  without  having 
to  think.  The  right  thing  in  health  will  be  done  by 
children  only  when  they  are  so  educated  that  they  do 
not  have  to  think  about  it. 

It  is  of  no  possible  use  to  tell  small  children  that 
dirty  finger-nails  may  harbor  disease  bacteria,  or  for 
us  to  talk  about  germs  at  all.  These  little  pupils  may 
successfully  repeat  what  is  said  to  them  about  such 
matters,  but  such  conceptions  are  never  really  grasped 
by  the  young  child.  The  habit  of  clean  hands  and 
nails  at  school  must  be  acquired  by  the  child,  not 
primarily  because  of  the  possible  danger  from  disease 
germs  on  dirty  hands,  but  because  clean  hands  are 
arbitrarily  desirable.  And  the  same  may  be  said  of 
habits  pertaining  to  clothing,  shoes,  the  hair,  the  teeth, 
and  various  other  personal  matters. 

The  kind  of  knowledge  which  is  desirable  at  this 
age  is  that  which  expresses  itself  in  useful  action.  It 
is  not  essential  that  young  pupils,  or  most  older  ones, 
should  learn  much  about  the  structure  or  anatomy 
of  the  body;  nor  is  it  necessary  or  desirable  for  any 
but  relatively  mature  pupils  to  understand  how  the 
body  does  its  work  (its  physiology).  But  even  the 
very  youngest  children  in  tlie  schools  are  not  too  young 
to  begin  to  learn  some  simple'Jbut  fundamental  prin- 
ciples in  respect  to  the  care  of  the  body,  about  some 


THE  TEACHING  OF  HYGIENE  225 

of  the  things  which  interfere  with  its  best  action,  and 
how  to  avoid  them.  This  is  true  hygiene. 

The  complete  study  of  the  human  body  is  one  of 
the  most  difficult  of  all  subjects.  No  piece  of  ma- 
chinery, however  complicated  it  may  be,  can  compare 
with  the  body  in  this  respect.  But  without  attempt- 
ing to  study  any  but  its  most  obvious  features  of  struc- 
ture and  action,  even  very  young  children  can  under- 
stand enough  about  this  human  machine  of  ours  to 
learn  how  to  take  the  best  care  of  it.  It  should  be  the 
purpose  of  hygiene  instruction  in  schools  "to  help 
young  people,  who  will  be  men  and  women  before  very . 
long,  to  know  the  truth  about  common  living,  and  to 
act  on  such  knowledge." 

Health  instruction  in  the  first  five  grades 

As  has  already  been  indicated,  no  formal  methods 
of  instruction  need  be  presented  before  the  sixth  grade. 
Instead,  teaching  effort  ought  to  be  concentrated 
upon  the  inculcation  of  health  habits. 

One  of  the  easiest  and  most  effective  methods  for 
helping  the  pupil  to  form  health  habits  at  this  time  is 
that  of  "personal  inspection."  This  need  never  prove 
embarrassing,  either  to  the  pupil  or  to  the  parent,  and 
when  properly  conducted  will  be  regarded,  first,  as  a 
source  of  entertainment,  and  second,  as  a  matter  of 
personal  pride,  until  at  last  health  habits  have  become 
an  inseparable  part  of  the  child's  life. 

Children  are  not  dirty  because  they  prefer  to  be  so, 
but  because  they  are  not  taught  the  pleasure  of  cleanli- 


226        HEALTH  WORK  IN  THE  SCHOOLS 

ness.  Nearly  all  the  rooms  of  the  lower  grades  in  our 
grammar  schools  are  offensive  to  the  sense  of  smell,  at 
least  to  the  individual  who  has  not  had  his  olfactory 
sense  perverted  through  constant  abuse  of  it.  This 
offensive  odor  is  due  in  large  part  to  dirty,  neglected 
bodies  and  clothes.  The  first  requirement  is,  there- 
fore, to  inculcate  the  love  of  personal  neatness  and 
cleanliness.  It  goes  without  saying  that  the  teacher 
herself  must  embody  this  principle  before  she  attempts 
to  impart  it  to  her  pupils.  In  some  rare  cases,  however, 
the  lesson  will  have  to  begin  with  the  reformation  of 
the  personal  habits  of  the  teacher. 

Personal  hygiene  inspection  by  teacher  and  pupils 

The  personal  inspection  of  pupils  must  be  adapted 
to  the  peculiar  needs  of  individual  conditions,  but  in 
the  main  may  follow  the  method  outlined  below. 

The  pupils  themselves  may  be  easily  taught  to  take 
part  in  this  inspection  by  the  teacher  appointing  the 
one  passing  the  best  inspection  to  act  as  inspector  of 
the  rest  of  the  class,  for  a  given  time.  The  complete 
inspection  need  not  be  introduced  at  once,  but  the 
pupils  may  be  led  very  gradually  into  it,  so  that  their 
interest  will  be  aroused  and  their  fears  or  prejudices 
overcome.  Other  points  not  mentioned  in  the  outline 
here  given  may  be  introduced,  at  the  discretion  of  the 
teacher,  and  in  order  to  meet  local  requirements. 
Some  points  may,  of  course,  be  omitted  for  the  same 
reason,  but  in  general  the  plan  here  suggested  will  be 
found  fairly  satisfactory  in  the  majority  of  schools. 


THE  TEACHING  OF  HYGIENE  227 

It  should  be  noted  that  in  this  personal  hygiene  in- 
spection the  questions  are  asked  so  that  the  negative 
answers  indicate  the  number  of  undesirable  conditions 
existing. 

Daily  inspection  of  pupils  in  the  first  five  grades 

1.  Are  the  hands  clean? 

2.  Is  the  face  clean? 

3.  Is  the  hair  clean,  well  brushed,  and  cared  for? 

4.  Are  the  nails  clean  and  neat? 

5.  Do  the  teeth  look  clean? 

6.  Has  the  toothbrush  been  used? 

7.  Are  the  ears  clean? 

8.  Is  the  clothing  neat  and  clean? 

9.  Are  the  shoes  neat,  clean,  and  well  fitting? 
10.  Does  the  child  have  a  handkerchief? 

Additional  information  to  be  obtained  by  the  teacher,  at  intervals 

1.  Is  at  least  one  window  kept  open  in  the  bedroom  at 
night? 

2.  Does  the  child  drink  coffee?  How  much? 

3.  Does  he  drink  tea?  How  much? 

4.  Does  he  always  have  breakfast? 

5.  What  does  he  usually  eat? 

6.  Does  he  always  have  lunch? 

7.  What  time  does  he  go  to  bed? 

8.  What  time  does  he  get  up? 

9.  Is  he  suitably  clothed? 

10.  How  often  does  he  bathe? 

11.  Is  he  required  to  do  any  work  for  pay?  What  sort? 

12.  Are  the  bowels  evacuated  daily? 

13.  Has  the  child  apparently  any  bad  sex  habits? 

14.  Does  the  child  use  an  individual  toothbrush? 

15.  Does  the  child  visit  a  dentist  at  least  once  every  year? 

In  the  grades  one  to  five,  inclusive,  little  need  be 
done  in  the  way  of  health  instruction  beyond  the  con- 
stant inculcation  of  health  habits.  In  grades  one  and 


228        HEALTH  WORK  IN  THE  SCHOOLS 

two  the  simple  daily  inspection  will  be  about  all  that 
will  be  necessary  or  indeed  successful. 

Inculcating  food  habits 

Beginning  with  the  third  grade,  when  the  average 
child  will  be  about  eight  years  old,  some  very  simple 
talks  about  foods  may  be  introduced.  It  will  be  pos- 
sible to  discover  what  the  child  usually  eats  at  each 
meal,  what  he  brings  to  school  for  his  lunch,  etc.  It  will 
be  possible  to  teach  these  little  people  that  they  must 
have  a  mixed  diet,  and  to  explain  in  common  words 
what  this  means. 

Peculiar  and  undesirable  food  habits  may  be  dis- 
covered and  corrected  at  this  time.  The  child  of  this 
age  can  be  taught  how  properly  to  masticate  his  food.  A 
visit  to  the  domestic  science  department  may  be  made, 
and  the  children  instructed  how  and  what  to  eat  by 
means  of  some  actual  meals  eaten  there  under  obser- 
vation. Simple  health  stories  will  prove  useful  at  this 
period  in  the  child's  education,  such  as  may  be  found 
in  Hall's  Primer  of  Hygiene.  These  stories  ought  to  be 
read  and  explained  by  the  teacher,  and  not  set  as  les- 
sons to  be  recited  by  the  little  pupils  (a  method  which 
never  accomplishes  any  good).  Proper  eating  habits 
may  be  rather  easily  acquired  at  this  time.  If  the  child 
in  the  third  grade  learns  how  and  what  to  eat,  his  in- 
struction in  hygiene  will  have  been  quite  satisfactory. 
Here  again  the  explanation,  or  why,  is  entirely  unneces- 
sary, and  has  little  or  nothing  to  do  with  the  formation 
of  good  habits. 


THE  TEACHING  OF  HYGIENE  229 

Other  health  habits  may,  of  course,  be  formed  at 
this  age,  and  the  teacher  must  use  her  judgment  about 
what  is  most  necessary  to  include  under  particular 
and  peculiar  conditions.  This  will  depend  largely 
upon  the  social  status  of  the  average  pupil  in  her  class. 

Vital  topics  of  hygiene  study  for  grades  three  to  five 

The  following  tabulated  suggestions  are  offered  as 
helpful  in  instructing  pupils  from  9  to  12  years  of 
age:  — 

1.  Make  lists  on  the  board  of  what  a  considerable  number 
of  pupils  had  for  breakfast. 

2.  From  this  make  a  list  of  the  good  foods,  and  another  of 
the  bad  foods. 

3.  Include  in  the  desirable  foods  such  things  as  milk, 
cocoa,  well-cooked  cereals,  bacon,  eggs,  toast,  bread 
and  butter,  cornbread,  crackers,  and  fruit,  —  particu- 
larly baked  apples  and  stewed  prunes. 

4.  Include  in  the  undesirable  foods  such  things  as  coffee, 
tea,  hot  breads  and  biscuits,  doughnuts,  and  hot  cakes 
of  all  kinds  when  used  to  the  exclusion  of  other  foods. 

5.  Make  a  list  of  breakfasts  which  fail  to  include  a  suffi- 
cient variety  of  foods. 

6.  Make  a  list  of  breakfasts  which  include  a  good  variety 
of  foods. 

7.  Note  how  many  children  report  breakfasts  principally 
made  up  of  coffee  and  bread;  coffee  and  doughnuts; 
coffee  and  crackers;  bread  and  syrup;  or  breakfasts 
which  include  only  starchy  foods,  or  exclusively  meat 
foods.  Learn  how  many  have  butter.  Note  how  many 
children  eat  no  breakfast.  Find  out  what  time  the  meal 
is  eaten ;  how  long  the  child  spends  at  breakfast ;  whether 
the  child  sits  at  table  when  he  has  his  breakfast. 

8.  If  necessary,  try  to  get  in  touch  with  the  parents  of 
children  who  have  inadequate  or  otherwise  undesirable 
breakfasts.    This  may  often  be  accomplished  by  the 


230        HEALTH  WORK  IN  THE  SCHOOLS 

school  nurse,  who  sometimes  works  miracles  in  home 
reform. 
9.  Simple  talks  on  the  care  of  teeth  may  now  be  introduced . 
They  ought  to  be  based  upon  actual  conditions  discov- 
ered in  the  class  by  the  teacher  in  the  daily  and  other 
inspections. 

10.  Simple  lessons  oh  the  value  of  good  air  may  be  intro- 
duced in  the  third  grade  and  carried  through  the  other 
grades.  The  young  child  is  not  interested  in  the  mechan- 
ical processes  of  ventilation,  but  may  easily  be  taught 
to  value  fresh  air  and  to  form  a  dislike  for  foul  air. 
Teach  the  child  at  this  time  how  to  detect  bad  air  by 
the  sense  of  smell,  and  encourage  him  to  observe  in 
this  way  the  conditions  present  at  school  and  at  home. 
Proper  breathing  habits  may  be  profitably  taught  now, 
and  the  teacher  will  be  surprised  to  discover  how  few 
children  know  how  to  breathe  in  the  right  way. 

11.  The  cleanliness  of  the  schoolroom  must  be  dwelt  upon, 
and  the  children  urged  to  take  part  in  keeping  it  free 
from  unnecessary  dirt. 

If  during  the  first  five  grades  the  daily  personal  and 
the  general  inspection  at  intervals  be  observed,  and 
knowledge  of  good  food,  fresh  air,  and  cleanliness  of 
environment  be  insisted  upon,  the  child  will  have 
formed  the  most  fundamentally  important  habits  of 
health.  But  the  teacher  must  never  forget  that  what 
she  is  teaching  is  not  "lessons,"  but  habits,  and  that, 
therefore,  she  must  never  fail  to  relate  each  and  every 
part  of  her  instruction  to  the  daily  life  of  the  pupil. 

To  sum  up  what  the  average  pupil  ought  to  have 
acquired  by  the  time  he  has  reached  the  sixth  grade, 
we  will  say :  — 

1.  He  ought  to  appear  at  school  with  reasonably  clean 
hands,  face,  ears,  and  body. 

2.  His  clothes  ought  to  be  neat,  and  free  from  avoidable  dirt. 


THE  TEACHING  OF  HYGIENE  231 

3.  His  shoes  ought  to  be  reasonably  clean,  and  well  enough 
fitting  to  avoid  injury  to  his  feet. 

4.  He  must  have  acquired  a  love  for  fresh  air,  and  an 
antipathy  toward  bad  air. 

5.  He  must  have  learned  by  experience  the  value  of  a  well- 
ventilated  bedroom  and  schoolroom. 

6.  He  must  have  learned  to  eat  properly,  and  to  know  in 
general  what  to  eat  and  what  not  to  eat. 

7.  He  must  have  learned  to  value  not  only  cleanliness  of 
person,  but  cleanliness  of  immediate  environment. 

8.  He  must  have  learned  how  much  to  sleep,  what  time  to 
go  to  bed,  and  what  time  to  get  up. 

9.  He  must  have  acquired  the  habit  of  evacuating  his  bow- 
els daily. 

10.  He  must  have  learned  to  value  a  clean  mouth  and  clean 
teeth,  to  use  his  toothbrush  daily,  and  to  visit  a  dentist 
at  least  once  a  year. 


Teaching  hygiene  in  the  sixth  grade 

Beginning  with  the  sixth  grade,  the  character  of 
hygiene  teaching  should  be  considerably  changed  from 
that  given  in  the  earlier  grades.  One  of  the  best  meth- 
ods for  presentation  to  children  of  this  age  (about  11 
or  12  years)  is  that  which  has  been  employed  with  re- 
markable success  by  the  Health  Department  of  New 
York  City  in  its  "Little  Mother's  League." 

Hygiene  lessons  dramatized 

Under  the  guidance  of  a  skillful  woman  physician 
and  school  nurse,  little  girls  of  10  to  12  years  of  age 
are  taught  simple,  practical  lessons  in  home  hygiene, 
including  such  things  as  the  care  of  milk,  foods  for 
babies  and  young  children,  the  general  care  of  babies, 
keeping  the  home  clean,  the  value  of  fresh  air,  and 


232        HEALTH  WORK  IN  THE  SCHOOLS 

other  useful  lessons  on  the  health  of  the  home.  Fol- 
lowing a  lesson  on  a  subject  such  as,  for  example,  the 
care  of  milk,  certain  children  (usually  two)  are  ap- 
pointed to  write  a  little  drama  and  present  it  before 
the  other  members  of  the  League.  This  method  in- 
terests the  children  tremendously,  and  impresses  the 
subject  upon  their  minds  more  effectively  than  any- 
thing else  could.  One  of  the  writers  of  this  book  wit- 
nessed such  a  play  given  by  a  division  of  the  "  little 
Mother's  League,"  of  New  York  City,  in  the  summer 
of  1911,  and  was  greatly  impressed  with  the  value  of 
this  sort  of  health  instruction. 

No  attempt  is  made  by  the  teachers  to  correct  the 
phraseology  of  the  actors  in  the  play,  but  they  are 
allowed  to  present  the  subject  exactly  in  their  own 
way.  The  only  requirement  on  the  part  of  the  teach- 
ers is  that  the  subject-matter  shall  be  essentially  cor- 
rect. This  means  that  children  teach  other  children  in 
words  of  their  own,  an  innovation  in  teaching  which 
accounts  for  the  wonderful  and  instant  success  which 
the  method  met  as  soon  as  it  was  introduced.  This 
method  may  be  easily  adapted  to  classes  in  the  public 
schools,  and  to  mixed  classes  as  well  as  to  little  girls 
alone.  It  seems  rather  remarkable  that  the  most  suc- 
cessful method  ever  devised  for  teaching  useful  health 
lessons  to  children  of  this  age  should  have  originated, 
not  in  the  public  schools,  but  in  a  great  city  health  de- 
partment which  has  not  ordinarily  been  looked  upon 
as  responsible  for  teaching  of  any  sort.  This  is  another 
illustration  of  the  fact  that  some  of  the  best  methods 


THE  TEACHING  OF  HYGIENE  233 

of  teaching  originate  outside  of  school  systems,  and  is 
in  line  with  the  growing  demand  of  to-day  that  teach- 
ing methods  and  lesson  materials  be  in  touch  with  the 
real  life  of  the  everyday  world. 

The  efficient  and  conscientious  teacher  will  at  once 
grasp  the  wonderful  possibilities  of  this  kind  of  in- 
struction through  play,  and  easily  adapt  it  to  all  the 
practical  needs  of  pupils  of  the  sixth  grade.1 

Reading  material  may  be  employed  at  this  time,  if 
desired,  although  this  is  not  in  the  least  an  essential 
requirement  for  any  but  the  teacher  who  is  devoid  of 
initiative  and  interest  in  her  subject.  The  writers 
would  mildly  protest  against  any  required  text  for 
pupils  of  this  grade,  but  would  recommend  supple- 
mentary reading,  of  which  there  is  now  fortunately 
available  an  abundance  of  the  best  sort. 

Outline  of  scheme  for  teaching  hygiene  in  the  sixth 
grade 

The  following  is  a  list  of  subjects  from  which  selec- 
tions for  discussion  may  be  made  by  the  teacher,  and 
followed,  in  some  cases,  with  appropriate  supplement- 
ary reading  by  the  pupils:  — 

1.  Care  of  milk. 

2.  Handling  of  food  at  home,  in  bakeries,  stores,  markets, 
etc. 

3.  Preparation  of  food. 

1  The  Louisa  Alcott  School  of  Boston  has  carried  this  idea  still 
further  by  the  use  of  models  of  all  kinds,  which  the  children  make. 
The  exhibit  of  this  school  at  the  International  Congress  of  Hygiene 
at  Washington  in  1912  was  most  impressive. 


234        HEALTH  WORK  IN  THE  SCHOOLS 

4.  Preservation  of  food. 

5.  Eating  habits. 

6.  Disposal  of  garbage. 

7.  Pure  water  supplies. 

8.  Disposal  of  sewage. 

9.  Water  and  purification. 

10.  Flies  and  their  control. 

11.  Mosquitoes  and  their  control. 

12.  Fresh  air. 

(a)  At  home. 
(6)  At  school, 
(c)  In  factories,  stores,  theaters,  churches,  etc. 

13.  The  skin. 

14.  The  teeth. 

15.  The  eyes. 

16.  The  ears. 

17.  The  nose  and  throat. 

18.  Colds. 

19.  Headache. 

20.  Personal  habits. 

(a)  Clothing. 
(6)  The  bowels. 

(c)  Play  exercise. 

(d)  Sex  habits. 

(e)  Sleep. 
(/)  Bathing. 
(g)  Work. 
(h)  Food. 

(i)  Coffee,  tea,  tobacco,  alcohol. 

Following  the  discussion  and  supplementary  read- 
ing of  the  subjects  indicated  in  the  list  given,  pupils 
should  be  asked  to  make  personal  observations,  re- 
port personal  experiences,  and  in  general  should  be 
encouraged  to  take  an  active  part  in  the  lessons. 
Technical  explanations  should  be  diligently  avoided, 
and  memory  work  discouraged. 

The  teacher  may  now  encourage  the  preparation 


THE  TEACHING  OF  HYGIENE  235 

and  presentation  of  health  plays  on  certain  profita- 
ble topics.  For  advice  on  this  subject  teachers  are  rec- 
ommended to  correspond  with  the  Division  of  Child 
Hygiene  of  the  New  York  City  Board  of  Health, 
requesting  details  as  to  the  management  of  the  "Lit- 
tle Mother's  League."  J 

1  For  references,  see  p.  251. 


CHAPTER  XV 

THE  TEACHING  OF  HYGIENE:  SEVENTH  AND  EIGHTH 
GRADES 

Early  instruction  must  deal  with  the  concrete 

When  the  pupil  has  passed  into  the  seventh  grade 
he  is  ready  to  begin  the  formal  study  of  hygiene.  Un- 

*  til  this  period  he  should  have  been  occupied  primarily 
in  establishing  proper  health  habits.  If  he  has  been 
led  along  the  right  educational  paths  he  will  have 
accomplished  this  object.  It  will  now  be  possible  to 
pay  less  attention  to  matters  of  personal  health,  and  to 
concentrate  attention  more  particularly  upon  matters 
of  environment.  At  this  time  it  will  be  possible  and 
desirable  to  begin  to  instruct  the  pupil  definitely  about 
bacteria  —  what  they  are,  what  they  do,  how  they  are 
carried  about.  To  attempt  to  do  this  before  the  child 
is  about  12  or  13  years  old  will  result  in  little  real  good. 
The  young  pupil  must  be  confronted  only  with  con- 
crete ideas,  ideas  rather  closely  related  to  his  daily 
experiences.  To  attempt  to  present  a  subject  which 
deals  with  the  invisible  world,  as  does  the  study  of 

4  bacteria,  is  to  violate  one  of  the  commonest  principles 
of  pedagogy,  namely,  that  the  child  must  be  led 
gradually  from  the  concrete  to  the  abstract,  from  the 
known  to  the  unknown.    Beginning  with  the  seventh 

.  grade,  however,  simple  demonstrations,  illustrating 


THE  TEACHING  OF  HYGIENE  237 

the  relation  of  germ  life  to  the  various  processes  of 
human  life,  may  be  successfully  introduced. 

Focus  attention  upon  healthy  rather  than  upon  disease 

The  teacher  cannot,  however,  be  too  careful  to  avoid 
focusing  attention  too  much  upon  disease.  The  whole 
object  of  hygiene  in  the  schools  must  be  to  teach' 
health,  not  disease.  How  to  keep  well  and  strong  is 
the  desired  object  at  this  time.  The  avoidance  of  dis- 
ease will  naturally  follow  when  the  pupil  is  properly 
instructed  in  the  simple  principles  of  health.  Several 
of  our  otherwise  useful  modern  texts  on  hygiene  for 
the  schools  err  in  this  respect,  with  the  result  that  a 
sensitive  child  is  more  likely  to  be  impressed  with  the 
morbid  rather  than  the  wholesome  in  daily  life. 

Some  hygiene  texts,  in  their  laudable  attempts  to 
escape  the  errors,  platitudes,  and  gross  exaggerations 
of  the  older  texts,  have  done  nearly  as  much  harm  in 
too  severely  adhering  to  the  pathological  scientific 
discoveries  of  the  day,  while  at  the  same  time  ignoring 
the  fact  that  the  child  has  not  acquired  any  true  per- 
spective which  will  enable  him  to  view  things  in  their 
proper  proportions.  People  may  be  easily  frightened 
by  too  much  truth,  or  rather  by  truth  presented  at 
too  acute  an  angle.  All  that  is  necessary  and  essential 
in  matters  pertaining  to  disease  may,  if  done  at  the 
right  time,  be  easily  presented  without  in  the  least 
frightening  the  child.  When  taught  in  the  right  way, 
and  opportunely,  modern  ideas  of  hygiene  and  sani- 
tation need  never  alarm  any  one. 


238        HEALTH  WORK  IN  THE  SCHOOLS 

Learning  how  to  meet  his  environment  constitutes, 
as  Professor  Huxley  long  ago  said,  a  liberal  education 
for  the  child.  It  is  never  ignorance,  but  knowledge, 
which  leads  to  health,  and  therefore  to  happiness. 
Man  has  always  been  most  afraid  of  those  things 
which  he  does  not  understand.  One  need  fear  dis- 
ease far  less  when  one  really  understands  its  nature 
and  how  easily  it  may  usually  be  avoided. 

Before  beginning  the  study  of  bacteria,  the  young 
student  will  do  well  first  to  observe  some  of  the  re- 
4  lated  forms  of  life  with  which  he  is  more  familiar.  For 
this  nothing  can  serve  a  better  purpose  than  common 
yeasts  and  molds.  Every  child  knows  what  these  are, 
but  few  know  just  how  they  grow  and  what  they  do. 

Practical  instruction  in  bacteriology  for  the  seventh  and 
eighth  grades 

For  further  suggestions  and  definite  explanations 
the  teacher  is  referred  to  Professor  Conn's  Bacteria, 
Yeasts,  and  Molds.  None  of  the  experiments  given 
require  any  special  training  or  technical  skill,  and 
therefore  no  teacher  need  feel  discouraged  from  at- 
tempting to  carry  out  the  directions  given. 

Apply  the  knowledge  gained  in  the  experiments  on 

bacteria,  yeasts,  and  molds  to  the  keeping-power  of 

various  foods;  to  the  condition  of  the  air  of  various 

rooms;  to  the  cleanliness  of  hands,  etc.1 

1  If  the  teacher  is  in  California,  she  should  apply  to  the  State 
Hygiene  Laboratory  at  Berkeley  for  a  set  of  demonstration  plates, 
illustrating  the  growth  of  bacteria.  In  connection  with  this  topic  the 
teacher  should  read  Conn's  Bacteria,  Yeasts,  and  Molds  (Ginn  &  Co.). 


THE  TEACHING  OF  HYGIENE  239 

The  teacher  must  make  it  very  clear  to  the  pupil 
that  bacteria,  yeasts,  and  molds  are  true  plants,  and 
therefore  dependent  upon  similar  conditions  for  their 
growth  as  plants  of  a  higher  nature.  She  must  also 
let  the  pupil  understand  that,  while  most  bacteria  are 
perfectly  harmless  plants,  disease  bacteria  are  spread 
about  in  the  same  way  as  the  harmless  variety. 

Have  the  children  note  how  colds  spread  in  a  room 
at  school,  and  ask  them  to  offer  explanations.  Apply 
the  knowledge  of  colds  to  other  forms  of  sickness. 
Ask  for  suggestions  on  the  prevention  of  the  spread  of 
diseases.  The  value  of  general  cleanliness,  pure  air, 
sunshine,  clean  food,  pure  water,  and  milk  must  be 
emphasized  at  this  time. 

Let  the  pupil  try  to  answer  the  following  questions 
after  having  completed  the  study  indicated  in  this 
section:  — 

1.  What  is  yeast? 

2.  How  does  it  get  into  food? 

3.  What  kind  of  food  does  it  need  for  growth? 

4.  How  does  it  grow? 

5.  Why  does  it  make  bread  rise? 

6.  What  effect  does  heat  have  upon  yeast? 

7.  Why  will  yeast  not  grow  in  preserved  fruit?  i 

8.  What  is  required  for  the  growth  of  molds? 

9.  On  what  sorts  of  things  do  molds  grow? 

10.  How  may  the  growth  of  molds  be  prevented? 

11.  Where  do  molds  come  from? 

12.  Where  are  bacteria  found  in  greatest  numbers? 

13.  Why  does  boiled  milk  keep  longer  than  raw  milk? 

14.  What  sort  of  milk  has  the  largest  number  of  bacteria? 

15.  What  is  a  good  test  of  clean  milk? 

16.  How  do  bacteria  get  into  food? 

17.  What  kind  of  air  has  the  greatest  number  of  bacteria  in  it  ? 


240        HEALTH  WORK  IN  THE  SCHOOLS 

18.  What  kinds  of  things  carry  bacteria? 

19.  How  may  food  be  kept  from  spoiling? 

20.  How  are  disease  bacteria  spread  from  one  person  to 
another? 

Teaching  hygiene  by  means  of  "sanitary  surveys" 

Following  a  general  study  of  bacteria,  in  the  manner 
outlined  in  the  preceding  section,  the  pupil  may  now 
be  interested  in  making  "sanitary  surveys"  in  his 
immediate  neighborhood.  The  plan  which  follows  is 
not  given  from  the  idea  that  it  ought  to  be  strictly 
followed,  but  merely  for  its  suggestive  value.  Teachers 
must  use  their  judgment  in  adapting  it  to  varying 
school  conditions.  In  some  instances  it  will  be  neces- 
sary to  simplify  the  questions;  in  other  instances  they 
may  be  considerably  amplified. 

Schools  in  rural  districts  must  have  surveys  ar- 
ranged for  them  which  will  meet  the  particular  prob- 
lems of  the  country:  city  schools  will  present  very 
different  sorts  of  problems  to  solve.  The  object  of 
these  surveys  is  to  get  the  pupil  in  touch  with  his  own 
particular  health  environment,  to  induce  him  to  be 
observant  of  actual  conditions  as  he  will  find  them  on 
the  way  to  and  from  school,  at  home,  on  the  city 
streets,  in  the  country,  in  the  school  building,  at  the 
dairy,  and  in  the  market  or  grocery  store. 

People  endure  unsanitary  conditions  because  they 
have  never  been  taught  anything  better.  Just  as  soon 
as  they  become  really  observant,  they  become  intoler- 
ant of  whatever  is  unwholesome.  Sanitary  education 
is  of  vastly  more  importance  than  sanitary  legislation. 


THE  TEACHING  OF  HYGIENE  241 

Pupils  in  school  do  not  become  interested  in  health 
through  reading  about  it,  any  more  than  they  suc- 
ceed in  acquiring  an  interest  in  language  through 
the  study  of  technical  grammar.  Whatever  the  pupil 
acquires  that  is  really  worth  while  he  gets  by  actual 
observation,  practice,  and  action. 

Knowledge,  to  be  of  any  value,  must  be  put  to  use. 
The  teacher  who  will  make  use  of  the  survey  plan,  as 
suggested  here,  will  be  astonished  at  the  results 
obtained,  both  in  respect  to  the  information  gained 
and  interest  aroused  in  the  pupil,  and  to  the  bene- 
ficial results  reacting  on  the  whole  community.  Such 
a  plan  recognizes  the  fact  that  the  pupil  is  an  embryo 
citizen,  and  seeks  to  prepare  him  for  efficient  citizen- 
ship in  his  own  town  or  city. 

The  following  sanitary  surveys  are  presented  as 
generally  suggestive  of  the  possibilities  in  the  study 
of  a  pupil's  health  environment:  — 

1.  Sanitary  survey  of  a  home. 

2.  Sanitary  survey  of  a  market. 

3.  Sanitary  survey  of  a  school. 

4.  Sanitary  survey  of  a  bakery. 

5.  Sanitary  survey  of  a  dairy. 


Sanitary  survey  of  a  home 


I.  Location. 

1.  Drainage. 

a.  Is  the  house  on  raised  ground? 

b.  Is  the  drainage  carried  off  on  all  sides 
by  natural  or  artificial  drains? 


Yes 


No 


1  These  surveys  are  to  be  made  with,  the  aid  of  the  teacher,  and, 
if  possible,  the  parents. 


242        HEALTH  WORK  IN  THE  SCHOOLS 


Sanitary  survey  of  a  home 


c.  Are  the  grounds  kept  free  from  stag- 
nant water? 
II.  Sunlight  and  ventilation. 

1.  Has  the  house  good  exposure  to  the  sun? 

2.  Has  it  good  exposure  to  the  air? 

3.  Are  the  rooms  most  used  on  the  sunny 
side  of  the  house? 

III.  General  interior. 

1.  Upon  entering  the  house  does  the  air 
seem  fresh  and  odorless? 

2.  Is  the  house  free  from  flies? 

3.  Are  there  at  least  two  outside  windows 
to  a  room? 

4.  Have  they  screens? 

5.  Is  the  heating  arrangement  adequate 
for  the  size  of  the  house? 

6.  Does  it  furnish  fresh  air  for  ventilation? 

7.  Is  the 'number  of  occupants  consistent 
with  the  size  of  the  house? 

8.  Is  the  plumbing  modern  and  open? 

9.  Are  the  lights  placed  so  as  to  avoid  a 
glare? 

10.  Can  the  floor  coverings  be  removed  and 
easily  cleaned? 

11.  Has  the  feather  duster  been  discarded? 

12.  Are  useless  hangings  and  decorations 
avoided? 

13.  Are  the  floors  clean  and  smooth? 

14.  Do  the  toilets  have  an  outside  window 
for  light  and  ventilation? 

IV.  Sleeping  apartments. 

1.  Are  there  fewer  than  three  occupants  to 
a  room? 

2.  Do  the  rooms  receive  sunlight,  at  least 
part  of  the  day? 

3.  Is  the  exposure  such  as  to  admit  the 
most  and  best  air? 

4.  Are  the  windows  open  from  the  top  and 
bottom  at  night? 


THE  TEACHING  OF  HYGIENE 


243 


Sanitary  survey  of  a  home 

Yes 

No 

5. 

Is  the  bed  placed  in  the  air  currents? 

6. 

Are  rugs  used  in  place  of  carpets? 

7. 

Are  bed  coverings  frequently  aired  and 
cleaned? 

V.  The  kitchen. 

1. 

Are  the  windows  well  screened? 

2. 

Is  there  a  cooler-closet  or  an  ice-box? 

3. 

Is  the  stove  well  ventilated? 

4. 

Are  the  sink  and  drain-pipe  kept  per- 
fectly clean? 

5. 

Is  the  food  kept  under  cover  or  screen? 

6. 

Is  the  source  of  milk  supply  known? 

7. 

Is  the  source  of  water  supply  known? 

8. 

Is  the  source  of  food  supplies  known? 

9. 

Is  the  filter  cleaned  out  every  day? 

10. 

Is  the  floor  kept  clean,  and  the  floor  and 
walls  painted  frequently? 

• 

11. 

Is  there  a  light  dry  room  in  which  per- 
ishable articles  of  food  may  be  stored? 

12. 

Is  the  ice-box  frequently  cleaned? 

13. 

Are  there  proper  toilet  facilities  con- 
nected with  the  kitchen? 

14. 

Are  clean  hand-towels  provided? 

15. 

Are  the  eating  utensils. of  sick  persons 
boiled? 

VI.  The  back  yard. 

1. 

Are  breeding-places  for  flies  avoided? 

2. 

Are    breeding-places    for    mosquitoes 
avoided? 

3. 

Is  the  yard  kept  free  from  rats  and  mice? 

4. 

If  there  is  an  outside  privy,  is  it  kept  in  a 
sanitary  condition? 

5. 

If  there  is  a  cesspool,  is  it  cleaned  out 
when  necessary? 

6. 

Are  wells  and  cisterns  protected  from 
drainage  from  contaminated  sources? 

7. 

Is  the  drinking-water  known  to  be  safe? 

8. 

Is  the  ground  kept  free  from  slops  and 
all  refuse  and  filth? 

244        HEALTH  WORK  IN  THE  SCHOOLS 


Sanitary  survey  of  a  meat  market 


L  Is  the  market  in  a  sanitary  location"? 

2.  Is  the  building  well  constructed? 

3.  Is  the  cellar  rat-proof?  • 

4.  Are  the  outhouses  and  stables  sufficiently 
removed? 

5.  Is  barnyard  refuse  and  market  refuse  fre- 
quently removed? 

6.  Are  the  general  premises  clean? 

7.  Are  the  meat  scraps  kept  in  metal  cans? 

8.  Are  the  premises  free  from  rats? 

9.  Are  the  floors  of  concrete,  or  other  imper- 
vious material? 

10.  Are  the  doors  made  to  swing? 

11.  Are  windows  and  doors  screened? 

12.  Is  the  place  free  from  flies? 

13.  Are  counters  made  of  marble,  or  glass,  or 
hard  wood? 

14.  Are  they  screened  to  prevent  handling  of 
meat? 

15.  Are  the  refrigerators  clean? 

16.  Are  clerks  clean  and  healthy -looking? 

17.  Are  they  well  protected  with  clean  aprons? 

18.  Is  all  meat  protected  from  flies  and  dust? 

19.  Are  tables,  trucks,  racks,  refrigerators, 
refuse   boxes,  floors,    and     tools    cleaned 

daily? 

20.  Is  the  source  of  meat  known? 

21.  Is  it  federally  inspected? 

22.  Is  it  city  inspected? 

23.  Is  the  meat  delivered  in  covered  wagons, 
and  kept  carefully  wrapped  until  it  reaches 
the  purchaser? 

24.  Are  the  carcasses  kept  carefully  wrapped 
while  being  transported  to  the  market? 

25.  Are  the  wagons  clean? 

26.  Are  the  refuse  wagons  covered? 


Yes 


THE  TEACHING  OF  HYGIENE 


245 


Sanitary  survey  of  a  bakery 


I.  Location  and  construction. 

1.  Is  the  building  in  a  sanitary  location? 

2.  Is  it  a  sufficient  distance  from  stables 
and  outhouses? 

3.  Is  barnyard  refuse  frequently  removed? 

4.  Is  the  cellar  rat-proof? 
II.  The  salesroom. 

1.  Are  the  doors  screened? 

2.  Are  they  double-hinged  (swinging)  ? 

3.  Is  the  food  kept  covered  under  glass? 

4.  Is  the  store  clean  and  free  from  flies? 

5.  Are  the  clerks  protected  by  clean  aprons  ? 
in.  The  bakery. 

1.  Is  the  dough  mixed  by  machine? 

2.  Are  the  floors  of  the  bakery  clean  and  dry? 

3.  Is  the  bread  wrapped  before  sending  it 
out  on  the  wagon? 

4.  Has  the  baker  or  any  of  his  employees 
tuberculosis,  or  any  other  contagious 
disease? 

5.  Are  they  clean  and  careful  in  personal 
habits? 

6.  Are  pet  animals  kept  out  of  the  bakery? 

7.  Is  there  night-work  in  the  bakery? 

8.  Is  the  ceiling  free  from  dirt  and  cobwebs  ? 

9.  Is  the  ventilation  good? 

10.  Are  there  windows  enough? 

11.  Are  the  storage  facilities  good? 

12.  Are  there  toilets? 

13.  Are  they  properly  located? 

14.  Is  there  a  place  for  people  to  wash  their 
hands? 

15.  Are  individual  towels  used? 

16.  Is  the   bakery  free  from  cockroaches 
and  other  vermin? 

17.  Are  utensils  and  machines  kept  clean? 

18.  Are  flies  kept  out? 

19.  Is  garbage  kept  covered  in  metal  cans? 

20.  Is  it  frequently  removed? 


Yes 


No 


246        HEALTH  WORK  IN  THE  SCHOOLS 


Sanitary  survey  of  a  school 


I.  Ventilation. 

1.  Are  the  rooms  well  ventilated? 

2.  Does  the  air  smell  clean  and  fresh? 

3.  Is  there  some  method  for  humidifying 
the  air? 

4.  Are  the  rooms  well  aired  at  recess? 
II.  Lighting. 

1.  Are  the  rooms  evenly  lighted? 

2.  Is  the  window  area  at  least  one  fifth  of 
the  floor  area? 

3.  Are  the  desks  so  placed  as  never  to  face 
direct  sunlight? 

4.  Are  dark  window-shades  avoided? 

5.  Are  yellow  or  linen-colored  shades  or 
Venetian  blinds  used? 

6.  Is  the  tinting  of  the  walls  light? 

7.  Is  the  ceiling  lighter  than  the  walls? 

8.  Is  over-decoration  avoided? 

9.  Does  all  the  light  come  from  one  side, 
the  left? 

10.  Is  there  eight  feet  of  space  between  the 
front  wall  and  the  first  window? 

11 .  Does  the  light  enter  the  room  from  the 
east  or  west? 

12.  Do  the  windows  reach  within  a  foot  of 
the  ceiling? 

13.  Are  the  seats  in  the  darkest  side  of  the 
room  no  farther  than  twenty-four  feet 
from  the  windows  ? 

HI.  Temperature. 

1.  Is  the  temperature  kept  over  65  degrees, 
and  less  than  70  degrees? 

2.  Is  there  a  thermometer  in  each  room? 

3.  Is  a  daily  temperature  chart  kept  in 
each  room? 

IV.  Cleaning  and  sweeping. 

1.  Has  the  feather  duster  been  discarded? 

2.  Is  a  damp  cloth  used  for  cleaning  up  dust? 


Yes 


No 


THE  TEACHING  OF  HYGIENE 


247 


Sanitary  survey  of  a  school 


3.  Are  the  windows  washed  at  least  three 
times  a  year? 

4.  Has  dry  sweeping  been  abolished? 

5.  Is  oiled  sawdust  used  on  the  floors  when 
sweeping  is  done? 

6.  Are  the  floors  oiled  at  least  twice  a  year? 

7.  Are  the  floors  free  from  sticky  oil? 

8.  Are  the  rooms  well  aired  at  the  time  of 
cleaning? 

9.  Are  the  desks  and  all  articles  of  furniture 
kept  constantly  clean? 

10.  Are  desks  re-dressed  at  least  every  two 
years? 

11.  Are  desks  washed  with  a  disinfectant 
when  necessary? 

12.  Is  the  common  use  of  articles  which 
might  carry  infection  avoided? 

V.  The  pupils  themselves. 

1.  Are  pupils  required  to  keep  their  hands 
and  faces  clean? 

2.  Is  the  clothing  of  the  pupils  reasonably 
clean? 

3.  Are  pupils  with  poor  eyesight  seated 
near  the  front? 

4.  Are  deaf  pupils  seated  near  the  front? 

5.  Are  pupils  with  skin  diseases  excluded? 

6.  Are  pupils  with  any  contagious  disease 
excluded. 

7.  Is  there  any  health  supervision  of  pu- 
pils? 

8.  Is  there  a  school  nurse? 

9.  Do  the   teachers   make   any   physical 
examinations  of  pupils? 

10.  Is  hygiene  taught?  How  is  it  taught? 

11.  Are  the  desks  adjustable? 

12.  Are  they  adjusted  to  the  pupils? 

VI.  General  sanitation. 

1.  Are  paper  towels  provided? 


Yes 


No 


248        HEALTH  WORK  IN  THE  SCHOOLS 


Sanitary  survey  of  a  school 


2.  Is  liquid  soap  provided? 

3.  Are  there  any  shower-baths? 

4.  Are  drinking-fountains  provided? 

5.  Is  the  common  drinking-cup  abolished? 

6.  Has  the  roller-towel  been  abolished? 

7.  Has  the  common  hand-towel  been  abol- 
ished? 

8.  Is  there  a  comfortable  lunch-room  for 
pupils. 

9.  Is  there  a  comfortable  rest-room  for 
teachers? 

10.  Is  there  a  "first-aid  "  emergency  outfit 
supplied? 

11.  Does  anybody  know  how  to  use  it? 

12.  Are  toilets  clean? 

13.  Are  toilet-rooms  well  ventilated? 

14.  Are  toilets  kept  flushed? 

15.  Is  the  basement  light  and  clean? 

16.  Are  the  school  grounds  kept  perfectly 
clean? 

17.  Is  the  drinking-water  safe  to  use? 

18.  Has  any  investigation  of  the  water  been 
made? 

19.  Are  ventilated  coat-closets  provided? 

20.  Is  fire  drill  practiced  frequently? 


Sanitary  survey  of  a  dairy 


I.  The  barn. 

1.  If  made  of  wood,  are  the  walls  fre- 
quently whitewashed? 

2.  Are  walls  and  ceilings  kept  clear  of 
cobwebs? 

3.  Are  windows  so  located  as  to  prevent 
direct  drafts  on  the  animals? 

4.  Is  the  barn  well  ventilated? 

5.  Are  floors  made  moisture-proof? 

6.  Are  gutters    (preferably   of  cement) 
provided  behind  the  stalls? 


Yes 


No 


THE  TEACHING  OF  HYGIENE 


249 


Sanitary  survey  of  a  dairy 


10 


11 


7.  Do  they  drain  properly? 

8.  Are  the  stalls  kept  clean? 

9.  Are  ceilings  dust-proof? 
Is  a  clean  wash-room  provided  for  the 
milkers? 

Are  paper  or  individual  towels  fur- 
nished? 

12.  Is  the  roller-towel  abolished? 

13.  Is  liquid  soap  provided? 
H.  The  milk-house. 

1.  Is  there  a  milk-house  separated  from 
the  barn,  and  used  for  no  other  pur- 
pose? 

2.  Is  it  clean? 

3.  Is  it  screened? 

4.  Is  it  provided  with  a  cement  floor? 

5.  Are  flies  kept  out? 

6.  Is  it  cool? 

7.  Is  the  milk  kept  covered? 

8.  Is  the  milk  cooled  to  at  least  50  de- 
grees? 

III.  The  utensils. 

1.  Are  all  utensils  kept  clean? 

2.  Are  pails,  cans,  and  bottles  and  other 
utensils  steamed  or  boiled  before 
using? 

Are  all  utensils  which  have  been  ex- 
posed in  a  house  where  there  has  been  a 
contagious  disease  carefully  sterilized? 
Is  the  patent  milk-pail  with  cover 
used? 

5.  Is  the  milk  milked  through  gauze? 

6.  Is  the  gauze  always  boiled  and  dried 
before  using? 

IV.  The  'premises. 

1.  Is  manure  removed  at  least  once  a 
week? 

2.  Are  domestic  animals  kept  away  from 
the  premises! at  the  time  of  milking? 


3. 


4. 


Yes 


250 


HEALTH  WORK  IN  THE  SCHOOLS 


Sanitary  survey  of  a  dairy 


Yes 


V.  The  surroundings. 

1.  Is  the  barnyard  clean  and  well 
drained? 

2.  Are  outhouses  well  removed  from  the 
vicinity  of  the  barn  and  milk-house? 

3.  Are  sheds  provided  for  animals? 

4.  Is  the  water  supply  safe? 

5.  Is  the  well  (if  any)  so  situated  that  no 
contamination  can  occur  from  a  privy 
or  other  source? 

6.  Is  all  sewage  contamination  of  water 
supply  avoided? 

7.  Are  garbage  and  manure  prevented 
from  accumulating? 

8.  Are  breeding-places  for  flies  avoided? 
VI.  The  animals. 

1.  Are  the  cows  kept  clean? 

2.  Are  the  cows  tuberculin-tested? 

3.  Are  all  the  cows  with  any  suspicion  of 
disease  kept  away  from  the  others? 

4.  Are  cows  kept  away  from  sewage- 
infected  streams? 

VTI.  The  milkers. 

1.  Do  milkers  wear  clean,  special  milk- 
ing-suits? 

2.  Do  milkers  keep  their  hands  clean? 

3.  Are  all  milkers  in  good  health? 

4.  Are  milkers  who  have  been  in  associa- 
tion with  cases  of  transmissible  dis- 
eases kept  away  until  danger  is  past? 

Vin.  The  "bunk-house." 

1.  If  a  house  for  milkers  is  provided,  is  it 
kept  clean? 

2.  Is  it  well  ventilated? 

3.  Is  there  a  suitable  wash-room? 

4.  Are  the  beds  clean? x 


1  It  is  not  expected  that  every  dairy,  and  especially  those  in  rural 
districts,  will  come  up  to  the  ideal  suggested  here,  but  they  should 
approximate  it  in  all  essential  matters. 


THE  TEACHING  OF  HYGIENE  251 

HELPS   FOR   THE   TEACHING   OF   HYGIENE    IN    THE 
GRADES 

Allen,  William:  Civics  and  Health.   1909,  pp.  411.  Ginn  &  Co. 

Denison,  Elsa:  Helping  School  Children.  1913,  pp.  352.  Harper  & 
Bros. 

Hoag,  E.  B.:  Health  Studies.  1909,  pp.  223.  D.  C.  Heath  &  Co. 

Hoag,  E.  B.:  Health  Pamphlets  for  Schools.  Whitaker  and  Ray- 
Wiggin  Co.,  San  Francisco. 

Hutchinson,  Woods:  We  and  Our  Children  (for  teacher  and  parent). 
Houghton  Mifflin  Co. 

Hutchinson,  Woods:  Hutchinson's  Health  Series.  Houghton 
Mifflin  Co. 

Putnam,  Dr.  Helen:  Report  of  the  Committee  on  the  Teaching  of 
Hygiene  in  Public  Schools.  Bulletin  of  American  Academy  of 
Medicine,  1905,  pp.  1-64.  Easton,  Pa. 

Ritchie  and  Caldwell:  Primer  of  Hygiene  and  Primer  of  Sanitation. 
World  Book  Co. 

Tolman  and  Guthrie:  Hygiene  for  the  Worker.  American  Book  Co. 

Wood  and  Reesor:  Health  Instruction  in  the  Elementary  Schools. 
1912,  pp.  140.  Published  by  Teachers  College,  Columbia  Univer- 
sity, New  York  City. 

See  also:  Bulletin  of  American  Academy  of  Medicine,  October,  1912. 
A  symposium  on  the  teaching  of  hygiene.  (Several  excellent  pa- 
pers.) Easton,  Pa. 


CHAPTER  XVI 

THE  TEACHING  OF  HYGIENE:  EDUCATION  WITH 
REFERENCE  TO  SEX 

The  'problem 

Every  teacher  should  have  a  true  conception  of 
the  frequency  with  which  ignorance  of  the  laws  of  sex 
is  responsible  for  sickness,  misery,  and  death,  indus- 
trial inefficiency,  the  infection  of  the  innocent,  and 
life-wreckages  of  many  other  kinds.  The  economic 
losses  accruing  from  such  ignorance  doubtless  exceed 
many  millions  of  dollars  annually  in  the  United  States 
alone,  while  the  more  important  ethical  and  moral 
losses  are  of  course  not  measurable  at  all.  An  ade- 
quate discussion  of  this  aspect  of  the  problem  would 
lead  us  beyond  the  limits  of  the  present  chapter,  and 
the  reader  is  accordingly  referred  to  the  judicious 
treatments  of  the  subject  by  Stanley  Hall,  Dr.  Prince 
Morrow,  and  Professor  Henderson.1  As  a  rule  even 
intelligent,  well-educated  persons  are  not  well  enough 
acquainted  with  either  the  moral  or  the  hygienic  im- 
portance of  the  problem.2 

1  See  references  at  end  of  this  chapter. 

2  Searching  investigations  made  by  our  most  reliable  authorities 
have  revealed  the  fact  that  the  prevalence  of  social  diseases  is  far 
greater  than  most  of  us  have  believed.  It  is  estimated  that  at  least 
60  per  cent  of  the  males  in  this  country  have  contracted  the  "red 
plague"  (gonorrhoea)  at  least  once,  and  that  2,000,000  of  our  people, 


EDUCATION  WITH  REFERENCE  TO  SEX    253 

Need  of  safeguarding  school  children 

Another  aspect  of  the  problem,  touching  the  school 
even  more  directly,  is  the  question  of  improper  sexual 
conduct  among  children  in  the  upper  grades  and  high 
school.  In  even  the  best  regulated,  coeducational  high 
school  there  is  almost  always  a  greater  or  less  under- 
current of  interests  and  events  which  are  unwhole- 
some even  when  they  are  not  positively  immoral. 
Sometimes  only  a  very  few  of  the  pupils  are  involved, 

many  of  them  innocent  women  and  children,  are  victims  of  the 
"black  plague  "  (syphilis).  Over  one  third  of  these  are  innocently 
infected.  Reliable  statistics  indicate  that  each  year  about  10  per 
cent  of  the  entire  adult  male  population  of  the  large  cities  are  treated 
for  one  or  the  other  of  these  diseases.  In  a  city  like  New  York  this 
amounts  to  almost  a  quarter  of  a  million  cases  annually,  or  more 
than  seven  times  as  many  as  the  number  of  cases  of  diphtheria,  scar- 
let fever,  smallpox,  measles,  and  chickenpox  combined.  Morrow 
estimates  that  20  per  cent  of  the  venereal  infection  is  acquired  before 
the  twenty-first  birthday.  Of  the  million  boys  who  arrive  at  puberty 
annually -in  the  United  States,  not  far  from  half  are  venereally  diseased 
within  a  few  years. 

These  conditions  are  not  peculiar  to  the  United  States,  but  are 
common  to  practically  the  entire  civilized  world.  Thus,  in  Germany, 
of  the  8,500,000  persons  included  in  the  industrial  insurance  regula- 
tions, 500,000  each  year  receive  sick  benefits  from  this  cause.  This 
is  about  6  per  cent  of  the  enrollment.  The  proportion  for  waitresses 
rises  to  13.5  per  cent,  for  young  salesmen  to  16.4  per  cent,  and  for 
university  students  to  25  per  cent.  For  a  study  of  the  moral  condi- 
tions in  American  colleges  the  reader  is  referred  to  Birdseye.  (See 
reference  3  at  end  of  this  chapter.) 

It  is  now  quite  well  known  that  about  one  third  of  all  blindness, 
and  80  per  cent  of  congenital  blindness,  is  due  to  ophthalmia  neona- 
torum, or  venereal  infection  of  the  child's  eyes  during  birth.  The 
social  diseases  are  responsible  also  for  about  one  half  of  the  internal 
surgical  operations  which  women  undergo,  for  perhaps  half  of  the  ster- 
ility, and  for  about  15  to  20  per  cent  of  the  admissions  to  our  insane 
hospitals. 


254        HEALTH  WORK  IN  THE  SCHOOLS 

sometimes  many;  children  from  the  "best  homes" 
hardly  less  often  than  others. 

Teachers  and  school  officers  too  often  rest  in  strange 
ignorance  of  things  which  pass  before  their  very  eyes. 
Often  they  are  indignant  if  the  problem  is  even  called 
to  their  attention,  blind,  it  would  seem,  to  the  very 
existence  of  this  most  imperious  and  most  pervading 
of  all  human  instincts.  But  when  overt  immorality 
among  their  pupils  stands  unmistakably  revealed, 
these  same  persons  are  the  ones  most  likely  to  turn 
with  heartless  severity  upon  the  offenders,  to  banish 
them  from  the  school  as  "degenerates. "  In  such  cases 
one  or  two  pupils  are  made  the  scapegoats  and  ex- 
pelled, as  though  to  vindicate  the  honor  of  the  school 
and  to  reestablish  the  self-respect  of  those  who  are 
responsible  for  its  reputation.  The  inhuman  and  un- 
sympathetic treatment  sometimes  meted  out  to  such 
offenders,  who  may  be  mere  children  and  sinned 
against  rather  than  sinning,  would  be  impossible  in 
any  man  who  had  not  completely  forgotten  the  storm 
and  fire  of  his  own  adolescense.1 

We  should  avoid  alike  the  folly  which  ignores  the 
evils  and  the  cruelty  which  combats  them  with  heart- 
less punishment  and  other  summary  measures.  We 
must  consent  to  face  honestly  and  without  prudery  or 

1  "  Of  all  cultivated  classes,  educators  alone  remain  timid  and  in- 
active. .  .  .  Teachers,  who  have  the  rarest  opportunity  to  observe, 
have  learned  nothing  and  ignore  the  truth."   (Stanley  Hall.) 

"The  very  persons  to  whom  to-day  we  have  to  look  to  effect  the 
sexual  enlightenment  of  children  are  themselves,  to  a  great  extent, 
also  in  need  of  enlightenment."   (Albert  Moll.) 


EDUCATION  WITH  REFERENCE  TO  SEX    255 

hypocrisy  the  actual  situation:  the  fact  that  in  most 
boys  and  in  many  girls  the  sexual  emotions  do  not 
lie  dormant  until  the  traits  of  will  and  character  have 
developed  sufficiently  for  their  proper  control;  the 
fact  that  very  few  boys  and  not  all  girls  reach  manhood 
or  womanhood  without  at  least  for  a  time  falling  vic- 
tims to  reprehensible  practices  or  conduct;  the  fact 
that  many  children  from  homes  otherwise  admir- 
able have  been  so  poorly  instructed  that  their  ideas 
of  sexual  matters  are  sufficiently  grotesque  and  dis- 
torted to  render  almost  any  kind  of  conduct  on  their 
part  pardonable  and  pitiable. 

The  entire  world  is  at  last  awakening  to  the  serious- 
ness of  the  problem.  In  almost  every  civilized  coun- 
try active  organizations  have  been  effected  for  the 
purpose  of  combating  the  evils  by  means  of  social, 
penal,  and  industrial  reforms,  and  by  more  thorough- 
going enlightenment  of  the  young. 

The  school's  relation  to  sex-education 

The  relation  of  the  school  to  the  entire  problem  of 
sex-education  is  fairly  well  indicated  by  the  expres- 
sions of  belief  regarding  the  following  propositions, 
submitted  in  1912  by  the  American  Federation  of  Sex 
Hygiene  to  leading  educators,  physicians,  and  public 
men  in  various  parts  of  the  country.  About  one  hundred 
replies  were  received,  for  the  most  part  from  just  those 
persons  who  by  virtue  of  their  interest  and  experience 
are  best  entitled  to  a  respectful  hearing  on  the  subject. 
The  propositions  and  votes  thereon  are  as  follows:  — 


256        HEALTH  WORK  IN  THE  SCHOOLS 

Proposition  I 
The  well-known  facts  concerning  the  widespread  igno- 
rance, misunderstanding,  and  misuse  of  the  human  sexual 
function  point  clearly  to  the  need  of  special  instruction  of 
young  people  in  the  scientific  principles  of  sex. 

Affirmative,  91;  negative,  0;  doubtful,  5. 

Proposition  II 
As  it  is  well  established  that  few  parents  are  both  quali- 
fied and  willing  to  give  their  children  this  vital  instruction, 
it  is  necessary  that  such  instruction  be  given  in  the  public 
schools,  both  elementary  and  high,  in  colleges,  and  in  other 
organized  educational  agencies. 

Affirmative,  73;  negative,  7;  doubtful,  11. 

Proposition  III 
The  scientific  basis  of  sex-instruction  should  be  laid  in  the 
biological  nature-study  of  elementary  schools  and  the  bio- 
logical courses  of  higher  schools  and  colleges.  Beginning 
with  the  nature-study  lessons  of  the  primary  grades,  life- 
histories  of  living  things  should  be  emphasized.  In  the  ad- 
vanced nature-study  of  the  grammar  grades  and  the  biology 
courses  of  the  high  school  there  should  be  a  gradual  presen- 
tation of  the  leading  biological  facts  of  animal  and  plant 
reproduction.  It  should  also  be  incorporated  in  courses  in 
hygiene  and  in  ethics. 

Affirmative,  80;  negative,  3;  doubtful,  3. 

Proposition  IV 
Specific  instruction  applying  the  biological  facts  to  human 
life  is  needed,  preferably  at  the  end  of  the  biology  course  in 
the  early  years  of  high  school. 

Affirmative,  75;  negative,  1;  doubtful,  2. 

Proposition  V 
Since  numerous  pupils  never  reach  the  high  school,  there 
is  need  of  some  definitely  organized  instruction  relating  to 
human  life  for  pupils  of  grammar-school  ages.    This  is  the 
most  difficult  problem  now  apparent. 

Affirmative,  73;  negative,  6;  doubtful,  9. 


EDUCATION  WITH  REFERENCE  TO  SEX    257 

Proposition  VI 
Provision  should  be  made  for  sex-instruction  in  evening 
schools,  in  forms  adapted  to  the  needs  of  various  types  of 
students. 

Affirmative,  72  negative,  1;  doubtful,  2. 

Proposition  VII 
In  order  to  appreciate  the  problems  and  cooperate  with 
special  teachers  all  teachers  should  know  the  fundamental 
biological,  hygienic,  and  ethical  facts  relating  to  sex-proc- 
esses. To  this  end,  teachers'  training-schools  should  offer 
courses  of  biology  and  selected  reading  which  give  the  needed 
knowledge. 

Affirmative,  82;  negative,  0;  doubtful,  8. 

Proposition  VIII 
While  the  nature-study  and  biology  classes  may  be  coedu- 
cational, as  abundant  experience  has  proved,  the  special 
application  of  biological  facts  to  human  life  should  be  in 
separate  classes. 

Affirmative,  82  negative,  0;  doubtful,  5. 

Proposition  IX 
Special  lectures  under  the  auspices  of  clubs,  churches,  and 
other  associations  interested  in  general  education  should  be 
established  in  order  that  the  sex-education  movement  may 
reach  parents  and  young  people  who  are  not  connected  with 
schools. 

Affirmative,  86;  negative,  0;  doubtful,  0. 

Proposition  X 
The  above  propositions  refer  to  instruction  in  normal  sex- 
processes.  Such  instructions  should  obviously  be  made  basal. 
But,  at  the  proper  time,  instruction  should  be  given  also  as 
to:  (1)  the  danger  of  unnatural  and  unhygienic  sex-habits; 
(2)  licentious  or  irregular  sexual  indulgence;  (3)  and  later,  the 
impressive  facts  relating  to  the  dangers  of  social  diseases, 
and  the  consequences  to  themselves  and  others.  Instruction 
in  regard  to  the  last  two  should  be  given  only  to  the  upper 
classes  of  the  high  school  and  to  students  in  college,  by  care- 


258        HEALTH  WORK  IN  THE  SCHOOLS 

fully  selected  instructors,  preferably  by  those  with  special 
training  in  medicine  or  physiology,  and  at  the  same  time  pos- 
sessing tact  and  skill;  but  all  teachers  should  be  prepared  to 
help  individual  students  who  may  need  advice. 

Affirmative,  85;  negative,  3;  doubtful,  2. 

Proposition  XI 
While  instruction  concerning  abnormal  conditions  is  largely 
a  problem  relating  to  adolescents,  some  direction  of  individ- 
uals is  sadly  needed  by  many  children  in  the  two  or  three  pre- 
adolescent  years;  and  it  is  to  be  hoped  that  every  school  will 
finally  have  one  or  more  competent  persons  (principal,  nurse, 
doctor,  or  teacher)  able  to  deal  effectively  with  the  individ- 
uals needing  help. 

Affirmative,  81;  negative,  0;  doubtful,  5. 

Proposition  XII 
The  introduction  of  sex-instruction  into  the  public  educa- 
tional system  should  be  made  carefully,  and  with  due  regard 
to  local  conditions,  such  as  the  attitude  of  school  officials, 
public  opinion,  and  the  availability  of  specially  trained 
teachers.  Nothing  could  be  more  undesirable  than  precipi- 
tate introduction  of  sex-instruction  by  propagandic  legisla- 
tors, or  by  over-zealous  school  officials.  Far  better  results 
are  to  be  expected  if  the  teachers  and  parents  interested  in 
each  school  are  first  awakened  to  the  need  of  special  instruc- 
tion; and  then  the  work  should  be  developed  gradually, 
quietly,  conservatively,  and  on  a  sure  foundation. 
Affirmative,  90;  negative,  0;  doubtful,  4. 

As  to  the  need  of  some  kind  of  education  of  the 
young  with  reference  to  sex  perhaps  every  reader  will 
agree  with  the  authorities  quoted.  We  cannot,  even  if 
we  would,  keep  the  child  long  in  the  innocence  which 
rests  upon  ignorance.  The  child's  interests  in  matters 
of  sex  are  far  more  precocious  and  far  more  intense 
than  appears  on  the  surface.  If  the  information  which 
is  sought  is  not  gained  from  sources  that  are  reliable 


EDUCATION  WITH  REFERENCE  TO  SEX    259 

and  pure,  it  will  be  found  in  sources  that  are  less  desir- 
able. There  is  no  third  possibility.  The  "conspiracy 
of  silence"  has  always  and  everywhere  proved  an 
utter  failure. 

Special  considerations  relating  to  sex  education 

The  points  on  which  disagreement  arises  have  mainly 
to  do  with  (1)  the  proper  place  for  the  instruction  to 
be  given,  whether  in  the  school  or  at  home;  (2)  the 
content  of  such  instruction;  (3)  the  method  of  ap- 
proach; and  (4)  its  appropriate  time  in  the  life  of  the 
child.  These  questions  can  be  answered  only  with  an 
understanding  of  their  relations  to  each  other,  and  in 
the  light  of  certain  general  principles.  The  subject  is 
too  difficult  to  make  dogmatism  safe.  The  following, 
however,  are  important  considerations:  — 

(a)  The  purpose  of  sex-education  should  not  be  too 
narrowly  conceived.  The  end  cannot  be  attained  by  a 
few  "sex-talks,"  stating  bluntly  the  facts  of  the  sex- 
life  and  painting  in  lurid  colors  the  evil  results  of  trans- 
gressions. The  purpose  of  such  education  is  much 
farther-reaching,  and  involves,  indeed,  the  gradual 
shaping  of  the  child's  attitude  toward  fundamental 
ethical  values,  the  patient  molding  of  a  whole  char- 
acter. 

(b)  We  must  clearly  understand  also  that  knowl- 
edge, alone,  does  not  meet  the  requirements  of  this 
kind  of  education.  Mere  information,  however  exact, 
does  not  insure  right  conduct.  The  problem  is  less  one 
of  enlightenment  than  of  moral  education.  The  will 


260        HEALTH  WORK  IN  THE  SCHOOLS 

must  be  made  the  master  of  the  instincts.  To  rein- 
force the  will,  the  "thou  shalt  not"  needs  to  be  re- 
placed by  the  uplifting  power  of  inspiring  ideals,  intel- 
lectual enthusiasms,  and  wholesome  respect  for  the 
integrity  of  body  and  mind.  The  life  needs  to  be  filled 
so  full  of  good  work  and  wholesome  play  that  super- 
fluous energy  will  not  seek  improper  outlets.  The 
sexual  instinct  is  not  to  be  so  much  repressed  as  sub' 
limated;  its  energies  directed  to  secondary  channels 
and  transformed  into  higher  values. 

(c)  The  school  needs  to  lay  greater  emphasis  upon 
the  broader  relations  of  moral  education,  which  should 
be  interpreted  to  include  training  in  social  cooperation, 
acquaintance  with  social  and  civic  responsibilities,  the 
inculcation  of  habits  of  personal  hygiene,  respect  for 
the  body  and  pride  in  its  capacities,  love  of  outdoor 
life  and  sports,  notions  of  chivalry,  preference  for  good 
literature,  a  taste  for  music  and  art,  etc.  Nor  can  the 
school  itself  be  an  effective  agent  in  moral  education 
until  its  own  moral  dangers  are  frankly  recognized. 
To  overwork  the  device  of  emulation;  to  lay  the  stress 
upon  getting  ahead  of  others;  to  neglect  the  multi- 
tudinous opportunities  offered  by  the  school  for  prac- 
tical training  in  social  duties  and  responsibilities;  to 
divorce  the  teaching  of  history  and  civics  from  all  ref- 
erence to  modern  social  and  industrial  environment; 
to  herd  adolescent  boys  and  girls  promiscuously  in 
crowded  schoolrooms  and  narrow  hallways  where  inti- 
mate physical  contact  is  possible  or  unavoidable;  to 
neglect  the  careful  chaperonage  of  school  children  on 


EDUCATION  WITH  REFERENCE  TO  SEX    261 

social  occasions,  school  picnics,  etc.;  to  induce  conges- 
tion of  blood  in  the  pelvic  regions  by  five  or  six  houis 
of  sedentary  work,  unrelieved  by  physical  activity;  to 
treat  all  reference  to  sex  problems  with  prudery  and 
repression:  —  all  of  these  mistakes  lay  a  burden  of 
guilt  upon  the  school  which  it  cannot  without  hypoc- 
risy deny.  When  the  school  has  cleared  itself  from  all 
blame  in  these  particulars,  and  has  set  a  thoroughly 
wholesome  environment  for  the  adolescent  boy  and 
girl,  it  will  be  in  better  position  to  campaign  for  the 
cooperation  of  parents  for  the  sex-education  of  chil- 
dren. 

(d)  Sex-pedagogy  differs  in  one  fundamental  par- 
ticular from  the  pedagogy  of  any  other  subject;  it 
must  not  seek  to  create  special  interest  in  the  material 
presented.  For  this  reason,  vague  allusions  which 
excite  curiosity,  and  pictures,  charts,  or  diagrams 
which  center  attention  upon  the  physiological  proc- 
esses of  reproduction,  are  to  be  avoided.  Some  of  the 
booklets  prepared  by  well-meaning  but  unpedagogical 
enthusiasts,  and  designed  for  the  use  of  the  pupil,  are 
thoroughly  vicious  in  this  respect. 

(e)  Wherever  the  special  instruction  is  given, 
whether  in  the  home  or  the  school,  timeliness  must  be 
observed.  Too  early  instruction  may  create  the  vices 
it  seeks  to  prevent.  The  greater  danger,  however,  is 
that  the  instruction  best  suited  for  each  period  of  de- 
velopment will  be  unduly  delayed.1 

1  "  Better  a  year  too  early  than  an  hour  too  late "  has  been  the 
slogan  of  the  reformers. 


262        HEALTH  WORK  IN  THE  SCHOOLS 

On  account  of  the  age  element,  mass  instruction  in 
sex-hygiene  by  school  grades  is  always  indefensible. 
A  fourth-grade  class  will  usually  be  found  to  contain 
children  all  the  way  from  8  to  13  years  of  age.  A  sixth- 
grade  class  may  range  from  10  to  15  years,  or  an  eighth- 
grade  class  from  12  to  17.  For  sex-instruction  chil- 
dren should  always  be  classified  by  ages,  not  by  grades. 

(/)  It  is  questionable  whether  mass  instruction  by 
means  of  "sex-talks,"  unrelated  to  other  lines  of  in- 
struction, should  ever  be  permitted,  even  when  the 
pupils  are  classified  on  an  age  basis.  Children  of  the 
same  age  may  differ  very  greatly  in  physiological  ma- 
turity, in  the  amount  of  sex-information  they  already 
possess,  in  innocence,  and  in  their  emotional  reaction 
to  the  instruction  given.  The  sudden  presentation  of 
the  brutal  facts  of  sex  is  almost  sure  to  prove  a  nervous 
shock  to  some  children,  in  whom  it  may  give  rise  to 
morbid  ruminations,  phobias,  etc. 

(g)  Just  here  lies  the  great  danger  in  exaggerating 
the  evils  of  solitary  vices.  The  views  commonly  held 
by  teachers  and  other  intelligent  people  on  this  point 
are  colored  by  the  extravagant  exaggerations  depicted 
in  the  literature  disseminated  by  quack  doctors.  If 
the  teacher  learns  that  a  feeble-minded  or  weakly  or 
incorrigible  child  in  her  class  is  guilty  of  such  practices, 
she  is  likely  to  conclude  that  the  defect  or  perversity 
is  due  solely  to  the  bad  habit.  It  is  now  universally 
admitted  by  the  best  medical  authorities  that  the 
evils  of  solitary  vice  are  in  most  cases  confined  prin- 
cipally to  their  indirect  effect  upon  morals,  self-respect, 


EDUCATION  WITH  REFERENCE  TO  SEX    263 

etc.,  and  to  the  resulting  shame,  worry,  and  other 
morbid  ruminations.  Nothing  but  evil  can  come  out 
of  scare-literature  or  scare-instruction.  Quartering 
people  alive  in  the  sight  of  the  public  did  not  stop 
crime,  nor  will  the  horrible  and  essentially  untruthful 
depictions  of  the  evils  of  impurity  lead  children  into 
paths  of  morality;  what  it  will  do  is  to  drive  a  good 
many  of  them  to  the  verge  of  insanity. 

Methods  and  content  of  instruction  by  stages 

Much  experimentation  will  be  necessary  to  deter- 
mine the  proper  content  and  the  most  effective  meth- 
ods of  sex-education.  Our  present  knowledge  and  ex- 
perience, however,  justify  the  following  tentative  out- 
line, which  is  offered  purely  for  whatever  suggestive 
value  it  may  have:  — 

One  to  six  years.  No  instruction  is  necessary  in  the 
first  half  of  this  period,  but  habits  of  cleanliness  should 
begin.  Sleep,  diet,  bathing,  etc.,  are  very  important. 
Care  should  be  exercised  with  regard  to  choice  of 
nurse.  Male  infants  should  be  circumcised.  Innocent 
habits  of  unnecessary  touching  and  handling  should 
be  guarded  against. 

At  this  period  the  trait  of  frankness  may  become 
deeply  implanted  in  the  child's  nature,  or  its  growth 
may  be  prevented  or  delayed.  Extreme  punishments 
breed  cowardice  and  destroy  confidence.  As  soon  as 
the  child's  curiosity  awakens  regarding  the  origin  of 
babies,  he  should  be  told  the  truth,  in  language  simple 
and  unevasive.  This  will  usually  occur  about  the  age  of 


264        HEALTH  WORK  IN  THE  SCHOOLS 

four  or  five  years.  The  instruction  at  this  point  need  not 
include  the  facts  about  paternal  relationship,  because 
the  child  has  not  yet  begun  to  wonder  about  this. 

Six  to  twelve  years.  In  the  first  half  of  this  period 
the  teaching  of  nature-study  should  acquaint  the  child 
gradually  with  the  processes  of  reproduction  in  plants. 
The  function  of  flowers,  pollen,  and  seed,  and  the 
method  of  fertilization  should  be  made  thoroughly 
familiar. 

The  program  for  the  second  half  of  this  period 
should  include  similar  study  of  typical  animals  below 
mammals,  —  fish,  birds,  insects,  etc.  Nature-study, 
in  the  broad  sense,  should  be  given  a  liberal  share  of 
the  program,  and  the  instruction  above  suggested 
could  be  related  in  such  a  way  to  the  general  processes 
of  nature,  and  so  gradually  and  opportunely  intro- 
duced, that  the  needed  information  will  be  assimilated 
without  attracting  morbid  attention  to  sex  as  such. 
Indeed,  the  child  will  not  be  consciously  aware  that  he 
is  receiving  sex-instruction. 

Sometime  during  this  period,  probably  between  the 
ages  of  seven  and  ten,  the  child  will  need  to  be  in- 
formed, in  a  general  way,  regarding  the  relation  of 
father  to  offspring.  The  exact  time  and  the  exact  ex- 
tent of  the  information  needed  will  depend  entirely 
upon  the  child's  spontaneous  curiosity. 

Indiscriminate  warnings  against  improper  habits 
should  not  be  indulged  in,  but  children  known  to  have 
formed  bad  habits  should  receive  private  instruction. 
Here,  as  elsewhere,  the  idea  should  be  to  make  virtue 

ft 


EDUCATION  WITH  REFERENCE  TO  SEX    265 

attractive  by  instilling  ideals  of  cleanliness,  strength, 
manliness,  chivalry,  etc. 

Twelve  to  fifteen  or  sixteen.  The  biological  and  hy- 
gienic phases  of  the  nature-study  program  may  now 
receive  still  further  emphasis.  The  study  of  animals 
may  be  extended  to  include  mammals,  the  function  of 
the  ovum,  modes  of  fertilization,  etc.  The  broader 
ethical  implications  should  be  stressed,  the  necessity 
for  care  of  the  young,  the  evolution  of  mother  love,  the 
significance  of  family  life  for  the  species,  etc.  As  before, 
this  will  be  incidentally  woven  in  with  the  rest  of  the 
course,  though  its  applications  to  human  life  can  be 
made  somewhat  more  explicit  than  in  the  earlier  stages. 
Because  of  the  prevailing  attitude  toward  sexual  mat- 
ters it  may  be  advisable,  where  possible,  to  present 
mammalian  zoology  to  boys  and  girls  in  separate 
classes. 

More  special  sex-instruction  at  this  period  is  also  of 
prime  importance.  Well  before  the  phenomena  of 
puberty  make  their  appearance,  both  boys  and  girls 
should  know  the  natural  developments  that  may  be 
expected  and  their  appropriate  hygiene.  It  is  shame- 
ful and  inexcusable  that  so  large  a  proportion  of  chil- 
dren reach  maturity  without  any  such  instruction 
whatever.  This,  no  doubt,  helps  to  account  for  a  fact 
which  several  studies  have  reliably  established,  —  that 
from  25  to  50  per  cent  of  women  suffer  from  menstrual 
disorders.  With  boys,  emphasis  should  be  placed  upon 
the  absolute  normality  of  emissions  during  sleep,  and 
upon  the  normality  and  healthfulness  of  continence. 


266        HEALTH  WORK  IN  THE  SCHOOLS 

Fifteen,  and  beyond.  The  teaching  of  biology  should 
here  be  amplified  to  include  the  chief  laws  of  heredity, 
human  physiology  with  special  reference  to  hygiene, 
the  bacterial  origin  of  disease  andthe  modes  of  trans- 
mission, eugenics,  etc.  For  the  first  time  full  particu- 
lars may  be  given  regarding  the  consequences  of  ven- 
ereal infection,  with  special  emphasis  on  the  dangers  to 
which  innocent  women  and  children  may  be  exposed. 

The  education  of  adolescent  girls  should  everywhere 
include  extensive  training  in  household  science,  and  in 
the  hygiene  of  physical  and  mental  development. 
Education  for  motherhood  should  be  its  conscious  and 
avowed  purpose. 

Summarizing,  we  may  say:  — 

(1)  That  sex-education  should  be  individualized 
and  adapted  both  in  method  and  content  to  the  child's 
stage  of  development  and  to  his  expanding  curiosity. 

(2)  It  will  be  mainly  of  two  kinds;  general  and  spe- 
cial. The  general  includes  the  broad  foundation  laid 
by  the  extensive  courses  in  nature-study  and  biology. 
The  special  includes  the  direct  instruction  about  sex- 
ual phenomena,  both  normal  and  morbid.  These  two 
types  of  instruction  will  not  necessarily  be  kept  entirely 
separate.  Indeed,  the  value  of  the  special  instruction 
will  depend  largely  upon  the  degree  to  which  it  is  made 
an  integral  and  logical  part  of  the  whole  process  of 
biological  enlightenment. 

(3)  Sex-education  must  never  be  considered  as  an 
isolated  problem,  but  as  one  related  to  the  whole  ques- 
tion of  moral  education.  Its  success  will  always  depend 


EDUCATION  WITH  REFERENCE  TO  SEX    267 

on  the  degree  to  which  it  is  supported  by  high  ideals, 
wholesome  enthusiasms,  and  a  right  attitude  toward 
the  social  world  in  general. 

Divided  responsibility  of  the  home  and  school  in 
sex-education 

We  are  now  in  better  position  to  say  where  sex-edu- 
cation belongs.  It  is  obvious  that  the  instruction  we 
have  designated  as  general,  the  biological  founda- 
tion, should  be  given  in  the  school.  It  belongs  there 
because  the  average  parent  has  neither  the  time  nor 
the  equipment  necessary  to  give  it.  The  school  has 
the  time  and  can  equip  itself  for  the  work  by  the  in- 
troduction of  laboratory  methods  into  the  elementary 
school,  and  by  extending  the  training  of  teachers  in 
hygiene  and  biology. 

It  is  equally  evident  that  the  instruction  designated 
as  special  belongs  partly  in  the  home  and  partly  in  the 
school.  The  more  personal  and  intimate  its  nature,  the 
more  such  instruction  becomes  the  proper  function  of 
the  home.  However,  a  great  deal  even  of  the  special 
instruction  can  and  should  be  woven  in  with  the  school 
work  in  nature-study  and  biology,  and  when  parents 
are  known  to  be  entirely  neglectful  of  their  duties  in 
this  respect  there  is  no  alternative  but  for  the  school  to 
assume  the  entire  responsibility  for  the  child's  sexual 
enlightenment. 

The  school  should  make  every  effort  to  enlist  the 
cooperation  of  parents  by  means  of  popular  lectures  to 
parent-teacher  associations,  conferences  with  parents 


268        HEALTH  WORK  IN  THE  SCHOOLS 

in  special  cases,  etc.  Rightly  prepared  pamphlets  ex- 
plaining the  need  of  sex-education,  indicating  what 
such  instruction  should  include  and  when  it  should  be 
given,  etc.,  would,  no  doubt,  perform  a  great  service. 
It  is  strange  that  this  method  has  been  so  little  used  in 
this  country. 

Finally,  the  complexity  of  the  problem  should  re- 
mind us  of  the  many-sided  cooperation  which  will  be 
demanded  for  its  satisfactory  solution.  We  may  men- 
tion, for  example,  its  relation  to  the  alcohol  question, 
to  the  social  control  of  prostitution,  to  industrial 
methods,  to  poverty,  to  public  recreation,  to  religion, 
to  law,  to  housing,  to  newspapers,  to  divorce,  to  child- 
dependency  and  child-labor,  to  the  reform  of  medical 
practice,  to  coeducation,  school  retardation,  feeble- 
mindedness, etc. 

SELECTED  REFERENCES 

(Recent  literature  on  this  subject  is  voluminous.  Only  a  few  of  the 
most  important  references  are  given  here.) 

*1.  Addams,  Jane:  A  New  Conscience  and  an  Ancient  Evil.   1912, 
pp.  219. 

2.  Bell,  Sanford:  "A  Preliminary  Study  of  the  Emotion  of  Love 
between  the  Sexes."  Am.  J.  Psych.,  1902,  pp.  325-54. 

3.  Birdseye,  C.  F.:  Reorganization  of  Our  Colleges.   1909,  pp.  410. 
(See  pp.  118-45.) 

4.  Cabot,  R.  C:  "The  Consecration  of  the  Affections."   Fifth 
Cong.  Amer.  Sch.  Hyg.  Assoc,  1911,  pp.  114-20. 

*5.  Eddy,  Walter  H.:  "An  Experiment  in  Teaching  Sex-Hygiene." 

J.  Ed.  Psych.,  October,  1911,  pp.  451-58. 
6.  Eliot,  Charles  W.:  "School  Instruction  in  Sex-Hygiene."  Fifth 

Cong.  Amer.  Sch.  Hyg.  Assoc,  1911,  pp.  22-26. 
*7.  Ellis,  Havelock:  Studies  in  the  Psychology  of  Sex.  Vol.  vi.   (See 
especially  chapter  n,  "Sexual  Education";  and  chapter  m, 
"  Sexual  Education  and  Nakedness.") 
8.  Foster,  W.  S.:  "School  Instruction  in  Matters  of  Sex."  J.  Ed. 
Psych.,  1911,  pp.  440-50. 


EDUCATION  WITH  REFERENCE  TO  SEX    269 

9.  Freud,  Sigmund:   Three  Contributions  to  the  Sexual  Theory. 
Nervous  and  Mental  Diseases  Monograph  Series,  no.  7,  New 
York,  1910,  pp.  91. 
10a.  Hall,  W.  S. :  From  Youth  to  Manhood. 

*10b.  Hall,  Stanley:  Educational  Problems.  1911.  (See  vol.  I,  pp. 
388-539.  This  is  the  broadest  and  most  scholarly  treatment  of 
the  subjects  yet  published.) 

*11.  Henderson,  Charles  R.:  "Education  with  Reference  to  Sex." 
Eighth  Y ear-Book  of  the  Natl  Society  for  the  Scientific  Study  of 
Education.  (Part  i,  "Pathological,  Economic  and  Social  As- 
pects," pp.  74.  Part  n,  "Agencies  and  Methods,"  pp.  89.) 

12.  Hodge,  C.  F.:  "Instruction  in  Social  Hygiene  in  the  Public 
School."  Bull.  Amer.  Acad.  Med.,  1910,  pp.  506-17.  (See  other 
papers  of  the  symposium  in  same  number.) 

13.  Jung,  C.  G.:   "The   Association   Method."    Am.  J.  Psych., 

1910,  pp.  201-69. 

14.  Kongress  der  deutschen  Gesellschaft  zur  Bekampfung  der  Ge- 
schlechtslcrankheiten,  Sexualpadogogik.  Leipzig,  1907,  pp.  321. 

15.  Mckeever,  William  A.:  "Instructing  the  Young  in  Regard  to 
Sex."  Home  Training  Bull.,  no.  8,  Manhattan,  Kansas,  pp.  16. 

*16.  Moll,  Dr.  Albert:  The  Sexual  Life  of  the  Child.  Translated  by 
Paul,  1912,  pp.339.  (See  pp.  179-219,  "  Importance  of  the  Sex- 
ual Life  of  the  Child  ";  and  pp.  246-325,  "  Sexual  Education.") 

*17.  Morrow,  Dr.  Prince:  Social  Diseases  and  Marriage.   1904. 

18.  Parkinson,  W.  D.:  "Sex  and  Education."    Ed.  Rev.,  January, 

1911,  pp.  42-59. 

19.  Putnam,  Dr.  Helen:  "Education  for  Parenthood."   Education 

1911,  pp. 

*20.  Report  of  the  Special  Committee  on  the  Matter  and  Methods  of  Sex 
Education;  Amer.  Federation  for  Sex  Hygiene,  New  York. 

1912,  pp.  34. 

21.  Schmitt,  Clara:  "The  Teaching  of  the  Facts  of  Sex  in  the  Public 
Schools."  Ped.  Sem.,  1910,  pp.  229-41. 

22.  Smith,  P.  A.:  "Sex-Education  in  Japan."  J.  Ed.  Psych.,  1912, 
pp.  257-63. 

23.  Smith,  Nellie  M.:  The  Three  Gifts  of  Life.   1913,  pp.  138. 

24.  Zenner,  P.:  Education  in  Sexual  Physiology  and  Hygiene;  A 
Physician's  Message.  Cincinnati,  1910,  pp.  126. 


CHAPTER  XVn 

THE  TEACHER'S  HEALTH1 

The  teacher's  health  is  an  important  though  neg- 
lected aspect  of  school  hygiene.  If  the  teacher  is  tuber- 
culous the  children  are  directly  exposed  to  contagion 
at  a  very  susceptible  period  of  life.  If  she  is  neuras- 
thenic, nervously  unstable,  querulous,  or  discontented, 
the  effects  upon  the  suggestible,  sensitive  child  may 
be  still  more  unfortunate.  The  welfare  of  children  is 
so  deeply  involved  that  it  is  no  longer  justifiable  to 
make  the  profession  a  haven  for  those  of  delicate  con- 
stitution. 

There  is  little  reliable  information  about  the  health 
conditions  among  our  half-million  teachers.  We  do 
not  know  definitely  their  mortality  rates  from  vari- 
ous diseases,  what  class  of  material  enters  the  pro- 
fession, to  what  extent  health  is  injured  by  the  work, 
or  what  measures  would  contribute  to  the  conserva- 
tion of  this  most  important  body  of  public  servants. 

Mortality  rate  and  physical  morbidity 

Balliett's  health  questionnaire,  submitted  to  159 
teachers,  indicated  that  persons  of  average  physical 

1  For  a  more  extended  discussion  of  this  subject  see  The  Teacher  s 
Health,  by  Lewis  M.  Terman.  Published  by  Houghton  Mifflin  Co., 
in  The  Riverside  Educational  Monographs,  1913,  136  pages. 


THE  TEACHER'S  HEALTH  271 

constitution  suffer  distinct  impairment  of  health 
within  five  to  ten  years  after  entering  the  profession. 

Of  five  hundred  New  England  and  Middle  West 
teachers  questioned  by  Dr.  Burnham,  37.4  per  cent 
stated  that  their  health  had  been  injured  in  greater 
or  less  degree  by  the  conditions  of  their  work.  The 
factors  blamed  were,  in  order  of  frequency,  poor  ven- 
tilation, bad  lighting,  nervous  strain,  standing,  noises, 
overcrowded  classes,  chalk-dust,  and  too  long  periods 
of  unbroken  work. 

In  Europe  more  extensive  data  are  available.  Sigel 
examined  all  the  teachers  of  Leipzig,  and  found  42.8 
per  cent  definitely  diseased.  Karup's  and  Gollmer's 
statistics,  from  12,381  German  teachers,  showed  a  low 
mortality  rate  from  all  causes  combined,  but  a  high 
susceptibility  to  tuberculosis  and  nervous  diseases. 

Statistics  from  the  National  Provident  Society  of 
English  Teachers,  including  18,000  members,  show  a 
high  morbidity  rate  from  throat  and  chest  troubles, 
influenza,  nervous  complaints,  and  gastro-intestinal 
disorders.  Each  year  about  12  per  cent  of  the  entire 
number  of  teachers  in  this  society  receive  sick  bene- 
fits. Records  of  retirement  under  the  English  Super- 
annuation Act  credit  one  third  of  the  breakdowns  to 
"neurasthenia, "  "nervous  prostration, "  and  "nervous 
debility." 

By  virtue  of  an  admirable  Swedish  law,  granting 
sick  allowances  to  teachers  who  have  been  ill  one 
month  or  more,  we  have  had,  since  1906,  complete 
morbidity  records  from  all  the  18,000  teachers  of  that 


272        HEALTH  WORK  IN  THE  SCHOOLS 

country.  An  average  of  4  per  cent  of  the  male  ele- 
mentary teachers  and  nearly  9  per  cent  of  the  female 
elementary  teachers  are  out  one  month  or  more  each 
year.  The  average  period  of  disability  is  4.9  months 
for  the  former  and  5.6  months  for  the  latter.  Nervous 
troubles  were  responsible  for  31.2  to  36  per  cent  of  the 
illnesses,  tuberculosis  for  6  to  9.3  per  cent,  other  re- 
spiratory troubles  for  13.7  to  17.9  per  cent,  ansemia 
and  general  debility  for  5.5  to  12.7  per  cent,  and  in- 
testinal troubles  for  7.6  to  8.9  per  cent.  We  are  also 
informed  that  2.5  per  cent  of  the  active  teaching  staff 
of  Sweden  are  sufferers  from  neurasthenia  of  "a  pro- 
nounced type,"  and  further  that  1.17  per  cent  of  the 
Swedish  female  teachers  are  tuberculous. 

If  these  figures  hold  for  the  United  States  our  neu- 
rasthenic teachers  would  number  about  12,500,  and 
our  tuberculous  teachers  about  5000.  The  former  are 
teaching  a  full  half-million  children,  the  latter  some 
two  hundred  thousand. 

Premature  superannuation 

Teachers  become  prematurely  superannuated.  After 
the  age  of  45  or  50,  new  positions  are  not  easily  ob- 
tained. At  an  age  when  the  lawyer,  physician,  min- 
ister, or  man  of  affairs  is  at  his  zenith,  the  teacher  is 
looked  upon  as  passee.  English  teachers  are  retired 
on  pension  at  an  average  of  53  years  for  males  and  51 
for  females.  The  average  age  for  superannuation  of 
male  teachers  is  49.1  years  in  Saxony,  and  51.7  in 
Hesse  and  Bayern. 


THE  TEACHER'S  HEALTH  273 

Tuberculosis  among  teachers 

The  mortality  of  teachers  from  tuberculosis  is 
especially  high.  In  Saxony  this  is  60  per  cent  higher 
for  the  years  20  to  29  than  for  the  general  male  popu- 
lation, and  23  per  cent  higher  between  30  and  39. 
In  the  Netherlands  for  the  ages  25  to  35  the  rate  is 
60  per  cent  higher  than  for  lawyers,  and  30  per  cent 
higher  than  for  physicians.  For  Switzerland  it  is 
10  per  cent  higher  than  for  the  general  population 
between  20  and  39  years,  and  30  per  cent  higher  be- 
tween 40  and  49  years.  From  a  careful  study  of  the 
prevalence  of  tuberculosis  among  the  3187  teachers  of 
Paris,  it  was  estimated  that  about  3  per  cent  of  the 
French  teachers  in  service  are  tuberculous. 

In  Ontario,  57  per  cent  of  the  deaths  among  female 
teachers  and  about  30  per  cent  among  male  teachers 
are  caused  by  tuberculosis.  The  corresponding  figures 
for  stone-cutters  are  65  per  cent,  for  lawyers,  25  per 
cent,  and  for  farmers,  16  per  cent.  Official  returns 
from  the  United  States  Census  Bureau  show  that  for 
ten  of  our  large  cities,  averaged  together,  39.6  per 
cent  of  the  deaths  among  female  teachers  are  caused 
by  tuberculosis,  39.1  per  cent  among  stone-cutters, 
26.8  per  cent  among  saloon-keepers,  and  13.9  per 
cent  among  farmers.  For  the  entire  census  registra- 
tion area  of  the  United  States  the  following  facts 
hold  with  great  constancy  and  uniformity:  (1)  That 
for  both  male  and  female  teachers  the  mortality  rate 
from  tuberculosis  ranges  from  19  to  26  per  cent  above 


274        HEALTH  WORK  IN  THE  SCHOOLS 

that  for  persons  of  the  corresponding  sex  in  other 
occupations;  and  (2)  that  for  female  teachers  the 
rate  is  from  39  to  43  per  cent  higher  than  for  male 
teachers. 

Mortality  rates,  after  all,  do  not  tell  the  whole 
story.  Teachers  belong  to  a  highly  selected  class,  both 
physically  and  morally,  and  ought  to  show  a  relatively 
low  mortality  rate.  They  also  suffer  from  many 
minor  complaints  which  do  not  greatly  affect  longev- 
ity, but  which  are  destructive  to  efficiency  and  to  the 
joy  of  living. 

The  teacher  as  neurasthenic 

Few  teachers  of  ten  years*  experience  have  escaped 
a  nervous  breakdown.  Probably  from  3  to  5  per  cent 
of  all  our  teachers  are  definitely  neurasthenic.  All 
the  studies  emphasize  the  exhausting  nature  of  the 
teacher's  work.  Of  the  305  German  teachers  reply- 
ing to  Wichmann's  questionnaire,  78  per  cent  suf- 
fered nervous  troubles,  the  leading  symptoms  being 
morbid  anxiety,  45  per  cent;  fixed  ideas,  35  per  cent; 
headaches,  71  per  cent;  heart  palpitations,  58  per  cent. 
These,  however,  are  not  average  conditions,  since 
the  questionnaire  no  doubt  elicited  a  disproportionate 
number  of  replies  from  those  who  were  ill. 

The  teacher's  short  day  is  more  apparent  than  real. 
The  conscientious  teacher  usually  begins  her  duties 
nearly  an  hour  before  the  class  is  assembled,  and  re- 
mains at  the  post  until  long  after  the  close  of  the  after- 
noon session.   The  teacher  who  can  manage  to  limit 


THE  TEACHER'S  HEALTH  275 

her  school  day  to  less  than  seven  hours,  exclusive  of 
evening  work,  may  consider  herself  fortunate.  In 
most  cases  evening  lessons  will  consume  one  or  two 
hours  additional.  Many  teachers  work  nine  or  ten 
hours  a  day. 

The  teacher's  work  cannot  be  adequately  measured 
in  terms  of  hours  and  minutes.  She  must  work  al- 
ways under  full  steam.  An  hour  of  teaching  is  prob- 
ably equivalent,  from  the  standpoint  of  fatigue,  to 
two  hours  of  ordinary  study,  done  in  quiet  without  the 
necessity  of  speaking.  Four  hours  of  actual  teaching 
thus  represent  about  eight  hours  of  ordinary  office 
work.  Add  to  this  two  hours  for  correcting  papers, 
preparing  lesson  plans,  supervising  plays,  etc.,  and  the 
four-hour  day  has  grown  to  one  of  ten. 

When  teachers  are  overworked  they  must  resort 
to  the  friendly  protection  of  mechanical  methods. 
Teachers  who  are  sweated  cannot  do  creative  think- 
ing. Overworked  teachers  degenerate  to  the  plane 
of  lesson-setting  and  lesson-hearing. 

Emotional  strain  is  added  to  intellectual  overpres- 
sure. Many  a  teacher  is  constantly  haunted  by  a  vague 
fear  of  unpleasant  conflicts  with  parents,  pupils,  or 
the  school  authorities.  Most  trying  of  all  is  the  neces- 
sity of  working  under  a  school  administrative  regime 
which  hedges  the  teacher  about  with  unnatural  re- 
straints and  destroys  her  individuality. 

Other  factors  are  overwork  in  the  normal  school, 
overcrowded  classes,  and  the  presence  of  exceptional 
children  in  the  regular  classes.   Pupils  who  are  incor- 


276        HEALTH  WORK  IN  THE  SCHOOLS 

rigible  or  backward  contribute  more  than  their  share 
to  the  worries  of  the  conscientious  teacher. 

The  investigations  prove  that  it  is  the  beginning 
teacher  who  runs  the  greatest  risk  of  pathological 
nervous  exhaustion.  With  47  per  cent  of  Wichmann's 
neurasthenics  the  nervous  troubles  appeared  in  less 
than  five  years,  and  within  fifteen  years  for  87  per 
cent.  The  reason  is  probably  threefold:  (1)  the  new 
teacher  is  more  prodigal  of  energy  from  excess  of  en- 
thusiasm and  because  she  has  not  learned  the  neces- 
sity of  mental  economy;  (2)  she  lacks  the  experience 
which  would  enable  her  to  work  with  the  least  ex- 
penditure of  effort;  and  (3)  the  early  years  act  as  a 
sieve  to  eliminate  all  but  the  strongest.  Whatever  the 
relative  shares  of  these  factors,  it  should  be  under- 
stood that  the  first  years  of  employment  are  critical 
for  the  teacher's  health.  To  ignore  the  laws  of  physi- 
cal or  mental  hygiene  at  this  period  is  to  sow  the  seeds 
of  lifelong  nervous  affliction  and  premature  super- 
annuation. School  administrators  can  aid  in  averting 
this  danger  by  lightening  the  burdens  of  the  young 
teacher,  by  instructing  her  in  economical  methods  of 
work,  and  still  more  by  patient  sympathy,  kindly 
criticism,  and  frequent  encouragement. 

Salaries  and  tenure  should  be  improved.  The  aver- 
age salary  of  the  American  teacher  is  about  $450.  It 
takes  $800  for  a  small  family  to  live  in  any  of  our 
larger  cities  in  the  style  of  a  common  laborer.  Teachers' 
incomes  are  as  little  conducive  to  physical  efficiency 
as  to  soul  expansion.  When  teachers  have  worn  them- 


THE  TEACHER'S  HEALTH  277 

selves  out  or  become  ill  in  the  public  service,  they 
should  not  be  turned  out  to  subsist  upon  the  charity 
of  friends,  but  should  be  granted  retiring  allowances. 

Health  suggestions  for  the  teacher 

The  teacher  should  learn  the  value  of  the  "factor 
of  safety"  in  mental  economy.  She  is  always  in  danger 
of  short-sighted  prodigality  of  energy.  To  live  up  to 
the  last  foot-pound  of  nervous  energy  daily  is  to  fall 
into  nervous  bankruptcy  at  the  first  emergency.  The 
teacher  should  find  the  safe  limits  for  her  day's  work, 
and  abide  well  within  them.  Sleepiness  and  the  feeling 
of  fatigue  are  the  twin  guardians  of  the  "factor  of 
safety."  If  their  warnings  are  not  heeded,  insomnia, 
worry,  and  nightmares  are  pretty  sure  to  follow. 

The  eyes  are  the  "weak  link"  in  the  health  of  many 
a  teacher.  Probably  from  10  to  20  per  cent  suffer 
from  unrelieved  but  relievable  eye-strain.  For  the 
teacher  to  carry  on  "correspondence  courses"  with 
her  pupils  is  to  invite  disaster.  To  face  a  light  for 
several  hours  a  day,  as  many  teachers  do,  is  alone 
sufficient  to  break  down  a  good  nervous  system.  When 
the  eyes  "go  bad"  the  best  oculist  in  reach  should  be 
consulted. 

If  the  teacher  would  be  healthy,  she  should  take 
varied  daily  exercise,  preferably  of  the  play  type. 
Hobbies  such  as  nature-study,  horseback  riding, 
tennis,  golf,  etc.,  are  to  be  commended.  Collateral 
work  of  sedentary  nature  is  to  be  avoided. 

Vacation  should  be  employed  in  such  a  way  as  to 


278        HEALTH  WORK  IN  THE  SCHOOLS 

rid  the  teacher's  brain  and  muscles  of  the  accumu- 
lated clinkers  of  a  school  year.  If  she  belongs  to  the 
well-known  variety  pedagogia  ancemia,  she  should 
carry  to  her  schoolroom  in  September  many  millions 
more  red  corpuscles  than  she  could  have  boasted  on 
the  previous  commencement  day.  For  the  teacher 
to  spend  her  entire  vacation  in  professional  study  is 
intellectual  as  well  as  physical  suicide.  The  vacation 
is  preeminently  a  time  for  striking  a  new  balance. 

No  one  has  more  reason  than  the  teacher  to  know 
something  of  dietaries  and  food- values.  Constipa- 
tion and  indigestion  drag  innumerable  teachers  along 
the  retrograde  path  to  professional  incapacity  and 
premature  superannuation.  Habits  of  living  and  eat- 
ing which  produce  costiveness  should  be  blacklisted. 
The  deadly  cold  lunch,  eaten  in  solemn  silence,  should 
be  forsworn.  Thanks  to  the  thermos  lunch-bottle  and 
basket,  the  cold  lunch  is  no  longer  a  necessary  evil. 

The  pedagogical  voice  is  expected  to  be  anything 
but  pleasant.  "Teachers'  nodes"  are  more  common 
than  "clergyman's  sore  throat."  The  teacher  has 
five  "voice  days"  per  week,  the  clergyman  but  one. 
The  teacher  should  therefore  guard  her  voice  as  some- 
thing more  than  an  instrument  of  communication. 
Success  or  failure  may  hang  upon  its  quality.  There 
is  the  voice  which  irritates  and  provokes,  and  another 
which  inspires  quiet  and  instills  respect.  In  short,  the 
teacher's  voice  is  more  important  than  her  grammar. 
She  can  preserve  it  and  improve  it  by  learning  how 
to  use  it  and  when  to  remain  silent. 


THE  TEACHER'S  HEALTH  279 

The  hygiene  of  character 

The  teacher's  work  is  likely  to  have  certain  reactive 
influences  upon  her  character.  The  social  instincts 
tend  to  atrophy.  Teachers  traditionally  are  bookish 
and  unpractical,  out  of  touch  with  civic  and  political 
affairs.  Living  an  individualistic  existence,  they  are 
always  in  danger  of  developing  provincialism  of  in- 
tellect and  character.  The  teacher  should  associate 
with  people  Outside  of  her  profession,  and  should  keep 
one  foot  in  the  living,  throbbing  world. 

The  social  instincts  of  the  teacher  are  also  subject 
to  perversions.  We  refer  here  particularly  to  male 
teachers,  who  so  often  are  characterized  by  effemi- 
nancy,  extreme  docility,  obsequiousness,  and  lack  of 
manly  force.  Not  a  few  superintendents  and  princi- 
pals become  dictatorial,  overbearing,  and  tyrannical 
toward  their  inferiors. 

The  classroom  teacher,  also,  may  become  dogmatic, 
exacting,  and  meddlesome  in  her  relations  to  the  chil- 
dren. Looking  always  after  their  faults  and  mis- 
takes, she  tends  to  lose  sympathy  and  generosity. 
She  develops  into  a  "Citizen  Fixit. "  Her  rules  be- 
come categorical  imperatives.  She  forgets  the  value 
of  the  personal  touch,  fails  to  utilize  the  leverage  of 
the  child's  natural  instincts  of  suggestibility,  loyalty, 
and  hero-worship,  and  becomes  prosy,  prodding,  and 
vexatious. 

Other  dangers  are  method-cult,  pedantry,  and  the 
didactic  habit.  Verbalism,  rules,  definitions,  and  pre- 


280        HEALTH  WORK  IN  THE  SCHOOLS 

ciseness  of  form  tend  to  replace  substance.  The  "rit- 
uals, "  called  parsing,  and  the  petty  exactitude  some- 
times required  in  the  formal  statement  of  arithmetical 
solutions,  are  good  illustrations.  Every  slightly  dif- 
ferent way  of  doing  a  thing  comes  to  be  labeled  with 
a  name  of  its  own.  Teachers  are  prone  to  overesti- 
mate the  value  of  what  they  teach,  some  of  which  is 
obsolete  fact,  misapplied  half-truth,  or  useless  pedan- 
try. 

The  result  of  all  this  is  likely  to  be  premature  mental 
decay.  The  constant  contact  with  little  minds  may 
dwarf  the  teacher's  own  mental  growth.  By  dint  of 
so  many  times  doing  the  same  thing  in  the  same  way 
she  falls  a  "victim  to  fixed  modes  of  interpretation." 
It  is  hard  to  be  spontaneous,  fresh,  and  inspiring  at 
the  hundredth  repetition.  New  categories  become 
less  and  less  possible.  The  personality  becomes  "shut 
in. "  When  this  state  supervenes,  intellectual  progress 
comes  to  an  end;  firm,  rigid  lines  settle  in  upon  the 
soul  —  it  is  habit-bound. 

How  to  prevent  mental  fixation 

An  important  antidote  is  to  reserve  certain  hours 
each  day  for  a  vacation  from  professional  habits.  This 
is  recreation,  which  therefore  should  become  the 
teacher's  religion.  It  should  involve  play,  the  very  es- 
sence of  which  is  its  creativeness  and  the  relaxation 
from  habitual  routine,  and  it  should  be  seasoned  with 
constructive  mental  activity  in  some  field  of  art,  lit- 
erature, science,  etc.   This  will  foster  the  attitude  of 


THE  TEACHER'S  HEALTH  281 

the  learner,  without  which  early  decay  is  certain.  The 
daily  recreation  will  need  also  to  be  reinforced  by  va- 
cations spent  in  travel  or  in  non-professional  study. 

The  teacher  should  cultivate  the  faculty  of  "doing 
the  usual  thing  in  the  unusual  way."  The  artist  tem- 
perament should  be  her  ideal,  for  the  true  artist  abhors 
exact  duplications  and  always  endeavors  to  transvalu- 
ate  all  his  experience.  In  every  possible  way  variety 
should  be  mingled  with  the  day's  routine.  Within  cer- 
tain limits  the  teacher  might  be  shifted  from  one  grade 
or  one  department  to  another,  or,  where  this  is  not 
feasible,  a  new  position  should  be  sought  occasionally. 
To  escape  the  danger  of  a  premature  mental  arrest, 
every  possible  source  of  life  and  enthusiasm  should  be 
utilized. 

The  responsibility  of  the  normal  school 

As  regards  the  first  of  these  points,  there  is  reason  to 
believe  that  the  intense  strain  of  the  normal  course 
directly  contributes  to  the  human  wreckage  which  lit- 
ters the  profession.  Hardly  any  one  will  deny  that 
normal-school  students  are  as  a  rule  overworked,  but 
the  overpressure  is  frequently  justified^onthe  plea  of 
necessity.  We  may  ask,  however,  whether  it  would  not 
be  wiser  to  lengthen  the  course  a  little  instead  of  defy- 
ing the  laws  of  nature-m  the  effort  to  crowd  three  years 
of  work  into  two,  or  four  into  three. 

In  the  second  place,  normal  schools  could  contribute 
to  the  hygiene  of  the  profession,  and  at  the  same  time 
to  the  protection  of  the  public,  if  they  would  conscien- 


282        HEALTH  WORK  IN  THE  SCHOOLS 

tiously  undertake  a  selection  in  the  admission  of  their 
students.  Before  entering  upon  the  training  course  all 
candidates  should  be  required  to  undergo  a  thorough 
physical  examination  made  by  experts  employed  by 
the  school  itself,  —  the  physically  unfit  to  be  rejected. 
The  examination  should  be  repeated  each  year  after 
entrance,  and  again  when  the  candidate  enters  upon 
regular  employment.  In  most  other  countries  such 
examinations  are  given  as  a  matter  of  course. 

In  the  third  place,  in  order  that  teachers  may  be 
placed  in  a  position  to  protect  themselves  from  those 
risks  to  health  and  happiness  which  are  sure  to  be 
encountered  in  the  practice  of  their  calling,  as  well  as 
also  for  the  sake  of  fitting  them  to  act  as  the  health 
guardians  of  their  pupils,  the  subject  of  school  hygiene 
should  be  raised  from  its  present  neglect  and  given  the 
right  of  way  in  the  normal-school  curriculum.  Instruc- 
tion in  the  subject  should  escape  its  present  absurd 
limitation  to  the  traditional  (and  sometimes  obsolete) 
laws  of  heating,  lighting,  and  ventilation,  and  ground 
itself  upon  the  newer  and  infinitely  broader  conceptions 
of  its  bearing  and  scope. 

Finally,  the  normal  school  could  contribute  to  the 
hygiene  of  the  profession  by  conscientiously  refusing  to 
place  its  stamp  of  approval  on  candidates  who  are 
careless,  ugly-tempered,  cynical,  and  void  of  sympathy 
for  children.  The  public  is  not  in  position  to  protect 
itself  against  poor  teachers  who  have  once  been  brev- 
etted  with  the  school's  diploma.  We  must  stop  the 
stream  of  undesirables  at  its  source. 


THE  TEACHER'S  HEALTH  283 

Vocational  guidance  for  teachers 

The  normal  school  could  also  profitably  engage  in 
the  work  of  vocational  guidance  of  its  students.  Here 
the  effort  would  need  to  go  beyond  the  mere  exclusion 
of  the  unfit,  and  include  the  direction  of  each  candidate 
into  that  type  and  grade  of  teaching  where  her  strong- 
est qualities  would  be  most  effective,  and  where  her 
weakest  would  least  imperil  her  success. 

Such  work  will  have  to  be  grounded  upon  a  positive 
body  of  facts  and  principles,  as  yet  largely  unknown, 
relating  to  the  psychology  of  teaching  success.  Its  aim 
will  be  to  distinguish  fundamental  traits  of  teacher- 
personality  necessary  for  success  in  various  lines  of 
teaching.  It  will  endeavor  to  place  the  teacher  where 
she  can  do  the  most  effective  work;  in  the  right  grade, 
in  the  right  subject,  with  the  right  sex,  and  in  the  most 
suitable  environment  generally. 

A  by  no  means  negligible  product  of  any  well-directed 
effort  toward  vocational  guidance  in  the  normal  school 
will  be  the  cultivation  in  the  young  teacher  of  a  spirit 
of  self-study  and  self-criticism,  which  throughout  her 
career  should  point  the  way  to  self-improvement,  to 
increased  success,  and  to  a  wholesome  spiritual  attitude 
toward  the  inevitable  vexations  of  the  profession. 

REFERENCES  « 

I.  The  Teacher's  Physical  Health 

*1.  Burnharn,  W.  H. :  "  A  Contribution  to  the  Hygiene  of  Teaching. 
Ped.  Sem.,  1904,  pp.  488-97. 

1  For  a  complete  bibliography  see  book  by  the  writer,  The  Teach- 
er's Health.  1913,  pp.  136.  Boston:  Houghton  Mifflin  Co. 


284        HEALTH  WORK  IN  THE  SCHOOLS 

*2.  Hoag,  E.  B.:  The  Health  Index  of  Children.  (Chapter  xi,  pp. 
136-52.) 

3.  Hulbert,  H.  L.  P.:  "The  Care  of  the  Teacher's  Voice."   Proc. 
Second  Inter.  Congress  Sch.  Hyg.,  1907,  pp.  862-66. 

4.  Lowden,  T.  S. :  "  The  Teacher's  Health."  Education,  vol.  xxix, 
pp.  30/.  and  153/. 

*5.  Oldright,  Dr.  William:  "The  Schoolroom  as  a  Factor  in  Tuber- 
culosis." Proc.  Second  Inter.  Congress  Sch.  Hyg.,  1907,  pp.  686- 
92. 
6.  Schmid-Monnard,  Dr.:  "Die  Ueberburdung  der  Lehrer  an 
hbheren  Lehranstalten."   Zt.  f.  Schulges.,  1899,  pp.  701-06. 
*7.  Small,  W.  S.:  "The  Hygiene  of  Teaching."    Proc.  American 

School  Hygiene  Assoc,  vol.  i,  pp.  142-52. 
8.  Steenhoff,  Dr.  G.:  "The  State  of  Health  of  Teachers  in  the 
Infant  and  Elementary  Schools  of  Sweden."  Inter.  Mag.  School 
Hygiene.    1911,  pp.  564-66. 
*9.  Terman,  Lewis  M.:    The  Teacher's  Health:  A  Study  in  the 
Hygiene  of  an  Occupation.   1913,  pp.  136. 
*10.  Van  Tussenbroek,  Dr.  Cathrine:   "Hygiene  des  Lehrkorpers." 

Rept.  First  Cong.  Sch.  Hyg.,  1904,  vol.  iv,  pp.  323-62. 
*11.  Wichmann,  Dr.  R.:  "Zur  Statistik  der  Nervositat  bei  Lehren." 
Zt.f.  Schulges.,  1903,  pp.  626,  696,  776;  1904,  pp.  304,  543,  713. 

12.  Williamson,  Dr.  R.  T.:  "The  Medical  Examination  of  School- 
Teachers."  (Chapter  xviii  in  Kelynack's  Medical  Inspection  of 
Schools,  1910;  same  article  in  the  Proc.  Third  Inter.  Cong.  Sch. 
Hyg.,  1910,  pp.  351-58. 

II.  The  Teacher's  Mental  Health  and  the  Hygiene  op 
Character 

13.  Adams,  J.:  "The  Dullness  of  Schoolmasters."  Ed.  Foundations, 
1911,  pp.  350-67. 

14.  Benson,  Arthur  C:  "The  Personality  of  the  Teacher."  Ed. 
Rev.,  1909,  pp.  217-30. 

15.  Burk,  F.  D.:  The  Withered  Heart  of  Our  Schools."  Ed.  Rev., 
December  1907. 

*16.  Hall,  G.  S.:  "Certain  Degenerative  Tendencies  among  Teach- 
ers."  Ped.  Sem.,  vol.  xn,  pp.  454-63. 

17.  Hughes,  Edwin  Holt:  "The  Reaction  of  the  Teaching  Profes- 
sion."  Educator-Journal,  1906,  pp.  223-30. 

18.  Terman,  Lewis  M.:  "The  Teacher  Psychosis."  Scribners 
Mag.,  November,  1908,  pp.  505-08  (published  anonymously). 

*19.  Zergiebel,  M.:  "Zur  Psychologie  des  Lehrers."    Zt.  f.  Ped. 
Psych.,  1911,  pp.  471-83. 


CHAPTER  XVIII 

WHAT  THE  WORLD  IS  DOING  FOR  THE  HEALTH  OF 
SCHOOL  CHILDREN 

The  purpose  of  this  chapter  is  to  give  a  brief  review 
of  the  progress  of  school  health  work  in  various  coun- 
tries. It  is  hoped  that  it  may  convey  at  least  a  general 
impression  of  the  breadth  and  profundity  of  a  move- 
ment which  with  us,  as  elsewhere,  has  developed  so 
suddenly  that  even  intelligent  people  who  happen  to 
be  uninformed  of  its  scope  and  fundamental  purposes 
are  likely  to  conceive  of  it  as  only  another  airy  decep- 
tion to  add  to  the  already  long  list  of  American  school 
fads. 

England 

Medical  inspection  in  England  was  not  a  growth, 
but  rather  a  sudden  national  awakening  to  the  fact  of 
racial  deterioration.  As  late  as  1902  there  was  no  ade- 
quate system  of  medical  inspection  anywhere  in  the 
country;  now  it  is  universal. 

England's  interest  in  physical  education  and  other 
problems  of  child  hygiene  received  its  first  great  im- 
pulse from  the  disclosures  of  the  results  of  conscriptions 
during  the  Boer  War.  The  fact  that  about  half  of  the 
army  volunteers  had  to  be  rejected  for  physical  unfit- 
ness touched  deeply  the  national  pride  of  England,  and 


286        HEALTH  WORK  IN  THE  SCHOOLS 

brought  a  keen  realization  of  the  dangers  of  national 
decay  through  the  physical  degeneracy  of  the  people. 
Numerous  investigations,  both  governmental  and  pri- 
vate, were  soon  launched  for  the  purpose  of  ascertain- 
ing the  extent  of  physical  deterioration  and  of  suggest- 
ing means  for  its  amelioration. 

In  1907  an  Education  Act  was  adopted  which  pro- 
vided for  a  compulsory  system  of  medical  inspection 
in  all  the  public  elementary  schools  of  England  and 
Wales,  a  system  probably  unsurpassed  in  any  other 
country.  The  act  became  effective  in  January,  1908, 
and  within  a  year  nearly  all  the  307  educational  dis- 
tricts of  England  and  Wales  had  complied  with  it. 

The  important  provisions  of  this  act  are  two  in  num- 
ber: (1)  medical  inspection  is  made  compulsory,  and  (2) 
the  duty  of  executing  it  is  specifically  imposed  upon 
the  education  authority.  It  is  provided,  however,  that 
the  education  authority  may,  if  it  sees  fit,  arrange  to 
have  the  work  carried  on  under  its  supervision  by  the 
public  health  machinery  already  in  existence.  Prac- 
tically it  makes  little  difference  which  course  is  pur- 
sued, since  it  places  the  responsibility  for  the  conduct 
of  the  work  upon  the  education  authority. 

As  interpreted  by  the  Central  Board  of  Education, 
the  aim  of  the  English  Education  Act  is  not  primarily 
the  medical  inspection  of  children,  but  their  physical 
and  mental  improvement.  The  subject  of  school  hy- 
giene is  related  in  every  possible  way  to  the  public 
health  work,  and  is  viewed  as  an  integral  factor  in  the 
health  of  the  nation.     Doctors,  teachers,  and  nurses 


WHAT  THE  WORLD  IS  DOING  287 

work  together  in  the  closest  cooperation.  The  aim  is 
not  merely  to  improve  the  health  of  the  children  who 
are  weakly  or  ailing,  but  in  the  broadest  sense  to  con- 
serve the  health  of  all  children  by  adapting  and  modi- 
fying the  system  of  education  so  as  to  make  it  fit  their 
needs  and  capacities. 

No  other  nation,  unless  it  be  Japan,  has  adopted  a 
school  medical  service  with  a  more  rational  conception 
of  its  true  purpose.  In  her  school  medical  clinics  Eng- 
land has  boldly  undertaken  the  free  medical  treatment 
of  her  ailing  children,  heedless  of  the  criticisms  of  the 
medical  profession.  Her  school  physicians  are  as  a  rule 
full-time  officers,  highly  trained  and  well  paid. 

The  leading  organ  of  school  health  in  England  is  the 
Journal  of  School  Hygiene,  published  since  1910. 

Germany 

Germany's  first  school  doctor  was  appointed  in  1883, 
at  Frankfort-on-the-Main.  By  1905,  100  cities  had  a 
total  of  598  school  doctors,  and  by  1908,  the  number 
had  risen  to  over  400  cities  and  1500  doctors. 

In  Germany,  medical  inspection  of  schools  has  not 
become  a  national  movement,  each  of  the  several  states 
composing  the  £mpire)acting  upon  its  own  initiative. 
Thus  far  only  two  states  have  a  state-wide  school  med- 
ical service  for  town  and  country  alike,  but  everywhere 
there  is  lively  agitation  looking  toward  an  extension  of 
the  work  to  rural  schools,  secondary  schools,  and  pri- 
vate schools  of  all  grades. 

German  school  doctors  are  nearly  always  part-time 


288        HEALTH  WORK  IN  THE  SCHOOLS 

officials.  Even  those  who  are  employed  for  full  time 
may  supplement  their  salaries  with  private  practice. 
The  pay  of  the  whole-time  doctors  ranges  from  $1750 
to  $2750,  with  pension  rights.  School  nurses  are  not 
very  commonly  employed,  and  the  effectiveness  of  the 
service  suffers  greatly  in  consequence.  There  are  many 
dental,  but  few  medical,  clinics.  The  school  doctor 
never  undertakes  to  give  treatment,  and  all  suggestions 
in  this  line  meet  with  vehement  opposition  on  the  part 
of  the  practicing  physicians.  As  stated  by  Fiirst, "  med- 
ical inspection  in  Germany  has  gone  only  a  little  way 
toward  its  real  goal  of  medical  supervision."  In  this 
respect  Germany  is,  with  certain  exceptions,  distinctly 
behind  a  number  of  other  countries. 

The  Wiesbaden  plan  of  medical  inspection,  which 
has  become  the  model  for  many  German  and  American 
cities,  deserves  special  mention.  It  provides  essenti- 
ally as  follows:  — 

1.  A  superficial  examination  of  all  new  entrants. 

2.  Following  this  a. thorough  physical  examination  of  new 
entrants  takes  place  within  six  to  eight  weeks  after  the  open- 
ing of  school.  The  results  of  the  examination  are  recorded 
for  each  child  upon  an  individual  "health  schedule,"  a  card 
which  contains  spaces  for  the  entries  of  health  data  secured 
from  all  the  examinations  made  during  the  entire  school 
life  of  the  child.  If  a  child  requires  continuous  medical  super- 
vision, the  doctor  inserts  the  words  "Medical  control"  at 
the  top  of  his  schedule. 

3.  Reexaminations  of  the  same  nature  occur  in  the  sec- 
ond, fourth,  sixth,  and  eighth  years  of  school  life. 

4.  The  school  doctor  visits  each  school  at  least  once  a 
month,  and  each  classroom  at  least  once  each  half-year. 

5.  All  cases  of  infectious  disease  coming  to  the  notice  of 


WHAT  THE  WORLD  IS  DOING  289 

the  head-master  must  be  reported  at  once  to  the  school 
doctor,  who  calls  and  inspects  the  class  to  which  the  patient 
belongs.  All  suspects  are  sent  home,  and  kept  under  ob- 
servation for  a  few  days.  Orders  for  school  closure,  disin- 
fection, etc.,  must  be  sent  by  the  school  doctor  to  the  local 
sanitary  authority. 

The  German  method  of  making  the  medical  examin- 
ation is  of  special  interest  because  of  its  thoroughness, 
and  might  well  be  recommended  to  American  school 
doctors.  As  described  by  Dr.  Fiirst,  it  takes  place  as 
follows :  — 

A  teacher  assists  the  school  doctor  by  writing  on  the 
health  schedules  at  his  dictation.  The  children,  who  have 
been  previously  weighed  and  measured,  approach  the  doctor 
in  turn,  stripped  to  the  waist  (including  the  younger  girls). 
Their  general  condition  is  noted,  then  the  chest  measure- 
ment taken;  the  neck  is  palpated,  and  glandular  swellings, 
enlarged  thyroid,  etc.,  are  noted.  The  mouth  is  inspected, 
and  the  condition  of  the  teeth  and  tonsils,  and  the  presence 
of  adenoids  noted.  The  nasal  and  aural  openings  are  super- 
ficially inspected  and,  if  suspicious  appearances  present 
themselves,  a  more  thorough  examination  of  these  is  made. 
The  back  is  now  inspected,  particular  attention  being  paid 
to  the  spine;  then  the  head  and  hair  are  looked  at.  Where 
appearances  of  illness  present  themselves,  or  the  child  com- 
plains of  pain,  etc.,  a  more  thorough  physical  examination 
is  made,  cases  which  cannot  be  satisfactorily  diagnosed  in 
the  presence  of  the  more  or  less  fidgety  class  being  reserved 
for  private  examination  after  the  others  have  been  dis- 
missed. 

In  other  ways  than  by  medical  inspection  Germany 
affords  us  admirable  examples  of  what  schools  can  do 
for  the  health  of  their  children.  Swimming  instruction 
is  often  obligatory,  and  school  shower-baths  are  be- 
coming extremely  common.   In  case  of  serious  spinal 


290        HEALTH  WORK  IN  THE  SCHOOLS 

curvature,  physical  exercises  of  a  corrective  nature  are 
prescribed  by  the  school  doctor,  and  carried  out  under 
his  direction.  Half-holidays  and  school  journeys  are 
common.  Over  two  hundred  cities  supply  from  one  to 
three  daily  meals  to  all  necessitous  school  children, 
municipal  grants  supplementing  private  benefactions 
for  this  purpose.  In  the  matter  of  special  schools  for 
defectives,  Germany  leads  the  world.  Up  to  1908  such 
schools  had  been  established  in  about  two  hunded 
German  cities.  The  open-air  recovery  school,  already 
noted,  is  only  one  of  the  many  types  of  special  schools 
in  Germany. 

In  the  amount  of  productive  research,  the  number 
and  value  of  its  manuals  and  texts,  and  in  its  high-class 
scientific  journals,  Germany  has  contributed  far  more 
to  the  cause  of  school  hygiene  than  any  other  country. 
The  following  are  some  of  the  most  prominent  German 
periodicals  devoted  to  school  hygiene  and  related  sub- 
jects :  — 

Zeitschrift  fiir  Schulgesundheitspflege.    Monthly.    Founded 

1888. 
Internationales  Archiv.fur  Schulhygiene.  Quarterly.  Founded 

1905. 
Das  Schulzimmer.  Quarterly  (1903-10). 
Eos.  Quarterly.  Founded  1905. 
Zeitschrift  fiir  Kriippelfiirsorge.  Quarterly. 
Soziale  Midizin  und  Hygiene.  Monthly. 

France 

Medical  inspection  began  in  France  as  early  as  1834, 
when  a  school  doctor  was  appointed  for  each  boys* 
school  in  Paris.    The  service  was  extended  to  girls' 


WHAT  THE  WORLD  IS  DOING  291 

schools  in  1843.  The  first  school  doctors,  however,  re- 
ceived no  salary,  and  did  little  real  inspection.  It  was 
not  until  1879,  when  Paris  organized  an  extensive  sys- 
tem, that  medical  inspection  in  France  could  really  be 
said  to  have  begun.  From  that  date  the  movement 
spread  rapidly  to  other  cities.  By  the  Education  Act  of 
1886  the  legal  position  of  medical  inspectors  was  fully 
established,  and  at  present  practically  all  the  cities 
have  a  system  based  more  or  less  intimately  on  that  of 
Paris. 

For  many  years  the  work  in  France  was  confined 
almost  entirely  to  sanitation  and  the  prevention  of 
contagious  diseases.  Only  a  few  cities  —  such  as  Nice, 
for  example  —  have  undertaken  the  careful  individual 
examination  of  all  of  their  school  children,  though  the 
attention  of  French  school  doctors  is  rapidly  turning 
to  the  fundamental  problems  of  child  hygiene. 

Other  notable  activities  conducted  by  French  edu- 
cational authorities  are  school  feeding  and  "vacation 
colonies. "  The  latter  have  recently  become  extremely 
popular,  so  that  it  is  not  at  all  rare  for  the  wealthier 
communes  (districts,  or  wards)  of  cities  to  purchase 
large  estates  in  the  country  for  the  special  use  of  vaca- 
tion colonies  for  school  children.  In  choosing  the  pu- 
pils for  such  excursions  preference  is  given  to  children 
who  are  anaemic,  feeble,  convalescent  from  acute  illness 
or  pre-tuberculous.  Some  districts  maintain  resorts 
both  at  the  seaside  and  in  the  country,  the  school  doc- 
tor deciding  which  place  would  be  of  the  greatest  ad- 
vantage to  a  given  child. 


292        HEALTH  WORK  IN  THE  SCHOOLS 

Mention  should  be  made  of  the  French  League  of 
School  Hygiene,  and  also  of  the  Society  of  Medical 
Inspectors  of  Paris  and  the  Seine.  Both  are  active 
associations,  the  former  publishing  the  quarterly  jour- 
nal entitled  L'Hygiene  Scolaire,  and  the  latter  the 
monthly  organ  La  Medecine  Scolaire. 

Switzerland 

All  but  a  few  of  the  cantons  of  Switzerland  have  a 
well-matured  system  of  medical  supervision  for  the 
cities,  and  some  of  them  have  extended  the  work  into 
rural  schools  as  well.  The  duties  of  the  school  doctor 
usually  include  the  complete  sanitary  supervision  of 
the  school  buildings  and  grounds,  and  the  examina- 
tion of  children  for  all  kinds  of  defects,  debility,  and 
mental  deficiency.  Both  Zurich  and  Geneva  have  re- 
markably efficient  school  medical  service.  Lucerne 
has  instituted  school  medical  and  dental  clinics.  The 
latter  registered  3443  attendances  in  1908-09. 

Owing  to  the  high  level  of  intelligence  and  education 
among  the  people  of  Switzerland  the  advice  of  school 
physicians  is  almost  invariably  acted  upon,  and  an 
elaborate  follow-up  service  is  unnecessary.  The  Swiss 
Society  for  School  Hygiene,  which  enrolls  over  seven 
hundred  active  members,  has  done  effective  work  in 
promoting  medical  inspection,  and  publishes,  besides  a 
Year-Book,  The  Swiss  Journal  of  School  Hygiene  and 
Child  Protection. 


WHAT  THE  WORLD  IS  DOING  293 

Sweden 

In  the  medical  inspection  of  schools  Sweden  has  long 
been  a  pioneer.  As  early  as  1868  all  the  public  secon- 
dary schools  in  the  kingdom  had  medical  officers  on 
their  staffs.  The  present  code  for  secondary  schools, 
which  dates  from  1905,  provides  for  the  appointment 
and  remuneration  by  the  Government  of  at  least  one 
medical  officer  for  each  school.1 

The  method  of  examination  is  almost  exactly  iden- 
tical with  that  provided  for  by  the  celebrated  Wies- 
baden plan,  and  so  need  not  be  described  in  detail.2  The 
duties  of  the  school  physician  are,  however,  of  decidedly 
broader  scope  than  in  most  other  countries,  in  that 
they  include  an  administrative  as  well  as  an  advisory 
function.  The  school  physician  is  expected  to  super- 
vise the  construction  of  new  buildings;  to  see  that  the 
sanitary  arrangements  are  satisfactory;  to  draw  up  a 
plan  of  procedure  for  janitors  and  other  employees,  and 
to  see  that  it  is  carried  out;  to  exercise  constant  over- 
sight of  the  methods  of  physical  education;  and  finally 
even  to  supervise  the  instruction  given  in  the  several 
branches  of  the  curriculum.  We  have  in  this  a  sugges- 
tion of  the  rapidly  broadening  scope  of  educational 
hygiene. 

For  the  public  elementary  schools  Sweden  has  not 
yet  established  a  general  system  of  medical  inspection. 

1  It  should  be  noted  that  Swedish  secondary  schools  correspond 
to  those  of  Germany,  and  not  to  those  of  the  United  States. 

2  See  p.  288. 


294        HEALTH  WORK  IN  THE  SCHOOLS 

However,  all  of  the  larger  cities  and  some  rural  com- 
munities support,  on  their  own  initiative,  a  school 
medical  service  similar  to  that  supplied  by  the  Govern- 
ment to  secondary  schools.  Foremost  of  the  Swedish 
cities  in  this  respect  is  Stockholm,  which  maintains  a 
system  of  examinations  similar  to  those  of  Wiesbaden 
and  Paris,  and  in  addition  has  set  the  notable  example 
of  voting  public  funds  for  carrying  on  research  in  school 
hygiene.  In  1906,  the  city  granted  to  Dr.  C.  Siindell 
the  sum  of  $495  for  the  investigation  of  schoolroom 
air,  in  relation  to  heating  and  ventilation;  $280  to  Dr. 
J.  Hanmar,  for  the  study  of  fatigue,  as  influenced  by 
various  forms  of  school  work;  and  $55  for  an  inquiry 
into  the  influence  of  vertical  and  slant  writing  upon 
sitting  posture.  The  budget  for  1907  included  appro- 
priations amounting  to  $1375  for  investigations  relat- 
ing to  school  hygiene.  Of  this,  the  sum  of  $440  was 
allotted  to  Dr.  Siindell  for  the  study  of  delicate  and 
anaemic  school  children,  and  of  the  home  conditions 
under  which  they  live;  to  Dr.  Hanmar  an  equal  amount 
for  the  continuation  of  his  study  of  school  fatigue;  and 
to  Dr.  K.  Soderling  about  $500  for  the  double  purpose 
of  investigating  the  possibilities  of  natural  lighting  of 
schoolrooms  (a  difficult  problem  for  a  part  of  the 
school  year  in  Sweden,  owing  to  the  high  northern  lati- 
tude), and  the  most  suitable  sizes  of  children's  school 
desks.  The  same  amount  ($1375)  was  appropriated  for 
investigations  in  1910. 

If  the  educational  authorities  in  all  parts  of  the 
world  were  simultaneously  to  emulate  this  example  by 


WHAT  THE  WORLD  IS  DOING  295 

undertaking  similar  investigations,  many  important 
and  challenging  problems  of  school  hygiene  would  soon 
be  brought  to  solution. 

In  regard  to  dental  clinics,  medical  dispensaries, 
school  feeding,  and  the  care  of  tuberculous  children, 
Swedish  schools  are  on  the  whole  abreast  of  the  most 
advanced  practices  in  other  countries.  Medical  treat- 
ment is  provided  in  many  polyclinics  and  in  at  least  six 
cities  by  free  dental  service. 

Denmark 

There  is  no  general  school  medical  service  in  Den- 
mark, and  such  inspection  as  has  been  carried  on  has 
been  directed  mainly  toward  the  control  of  infectious 
diseases.  However,  Copenhagen,  Frederiksberg,  and 
a  few  of  the  larger  provincial  towns  have  undertaken 
medical  inspection  on  their  own  initiative,  adopting 
in  most  cases  the  Wiesbaden  system.  Copenhagen  has 
one  part-time  physician  for  2000  to  4000  children, 
while  Frederiksberg,  with  its  8000  school  children, 
employs  one  for  full  time.  The  Tuberculosis  Act  of 
1905  has  led  to  an  excellent  and  uniform  method  of 
janitor  service  for  all  state-managed  schools. 

Norway 

Since  the  Education  Act  of  1896,  Norway  has  re- 
quired medical  inspection  of  all  its  public  secondary 
schools.  Since  1889  there  has  been  a  permissive  law 
for  public  elementary  schools,  in  towns  which  are  will- 
ing to  meet  the  expense.  Most  towns  now  have  such 


296        HEALTH  WORK  IN  THE  SCHOOLS 

inspection.  As  a  result  of  the  Tuberculosis  Act  of  1901, 
special  attention  is  now  given  to  children  who  appear 
anaemic  or  otherwise  debilitated. 

Scotland 

In  1902,  while  the  Boer  War  was  in  progress  and  the 
British  nation  was  effectively  roused  to  questions  of 
physical  degeneracy,  King  Edward  VII  appointed  a 
committee  of  nine  to  inquire  into  the  state  of  physical 
training  in  the  schools  of  Scotland.  The  committee 
was  composed  of  some  of  Scotland's  most  eminent 
statesmen  and  physicians.  There  resulted  in  1908  the 
Education  Act  of  Scotland,  which  conferred  upon  the 
971  school  boards  the  powers  necessary  for  a  complete 
system  of  medical  inspection.  While  this  act  is  nomin- 
ally not  mandatory,  it  is  so  in  effect.  Practically  all 
schools,  whether  primary,  secondary,  or  technical, 
including  continuation  schools,  must  either  provide 
for  medical  inspection  or  give  facilities  to  the  school 
board.  Even  private  schools  may  provide  medical 
inspection  at  public  expense.  The  counties,  as  a  rule, 
provide  the  same  excellent  system  as  do  the  large 
cities. 

As  in  England,  the  child  hygiene  movement  in  Scot- 
land has  progressed  with  almost  incredible  rapidity. 
According  to  a  recent  provision,  all  candidates  for  the 
teaching  profession  are  required  to  take  a  course  of 
training  in  school  and  personal  hygiene  embracing  not 
less  than  seventy  hours.  For  this  purpose  seven  full- 
time  and  two  part-time  physicians  are  employed  as 


WHAT  THE  WORLD  IS  DOING  297 

lecturers  by  the  four  training  schools  for  teachers. 
The  same  physicians  also  medically  examine  all  stu- 
dents in  training,  both  at  the  beginning  and  the  end  of 
their  course.  The  College  of  Hygiene  and  Physical 
Training,  founded  by  the  Carnegie  Dunfermline  Trust, 
provides  highly  qualified  special  teachers  of  hygiene. 
Glasgow  and  Edinburgh  support  special  schools  for 
physically  and  mentally  defective  children,  but  thus 
far  there  are  few  open-air  schools  in  Scotland.  One  of 
the  most  important  of  all  statistical  documents  yet 
published,  for  the  study  of  the  sociology  of  the  school 
child,  is  the  Report,  by  Dr.  W.  Leslie  Mackenzie  and 
Dr.  A.  Foster,  on  The  Physical  Condition  of  Children 
attending  the  Public  Schools  of  Glasgow.  The  cause  of 
child  hygiene  in  Scotland  owes  an  incalculable  debt  of 
gratitude  to  the  pioneer  efforts  of  Dr.  Mackenzie. 

Ireland 

In  matters  of  school  hygiene  Ireland  affords  the 
most  shocking  conditions  to  be  found  in  any  country 
which  lays  claim  to  civilization.  The  facts  as  presented 
by  the  most  responsible  writers  and  observers  sound 
incredible. 

A  majority  of  the  buildings  are  deplorable  struc- 
tures, extremely  small,  low,  thatched  but  not  ceiled, 
"old,  decayed,  rat  infested,  base,  and  unsightly  hov- 
els." Many  are  filthy,  squalid,  damp,  miserably 
lighted,  and  absolutely  without  ventilation.  Sometimes 
as  many  as  80  children  are  crowded  into  a  room  13  X23 
feet,  and  retained  there  from  10  until  2  o'clock  without 


298        HEALTH  WORK  EST  THE  SCHOOLS 

intermission.  The  atmosphere  becomes  pestilential 
and  sickening.  The  seats  are  universally  crude  and  ill- 
fitting.  One  eighth  of  the  elementary  schools  of  Ireland 
are  without  toilet  conveniences  of  any  kind.  There  is 
often  no  janitor  work  beyond  what  teacher  and  pupils 
do  voluntarily,  nor  in  many  schools  is  there  any  provi- 
sion for  heating.  One  third  of  the  schools  of  Belfast 
have  no  playgrounds  whatever. 

The  inevitable  results  of  this  neglect  appear  on 
every  hand.  The  mortality  of  school  children  is  higher 
than  for  the  population  generally.  Epidemics  of  mea- 
sles, scarlet  fever,  whooping-cough,  etc.,  are  frequent. 
Between  the  ages  of  10  and  15  years  the  death  rate 
from  tuberculosis  is  appalling,  while  the  relative  health- 
fulness  of  the  children  below  school  age  points  unequi- 
vocally to  the  cause. 

Canada 

Ontario  passed  a  permissive  act  in  1909  and  medical 
service  has  been  inaugurated  in  Hamilton  and  Brant- 
ford.  Manitoba  passed  a  similar  act  in  the  same  year, 
and  Winnipeg  at  once  availed  itself  of  the  legislation. 
The  Province  of  British  Columbia  adopted,  in  1910,  a 
thoroughgoing  medical  service  for  all  the  city  and  rural 
schools. 

The  city  of  Montreal  has  had  school  medical  service 
since  1906.  Interest  in  the  question  was  first  aroused 
by  the  Montreal  Women's  Club,  which  in  1902  began  a 
campaign  of  education  looking  toward  this  end.  After 
four  years  of  agitation  their  efforts  were  successful. 


WHAT  THE  WORLD  IS  DOING  299 

The  emphasis  is  primarily  on  the  prevention  of  con- 
tagious disease  and  the  improvement  of  sanitation, 
though  the  work  has  incidentally  had  other  favorable 
results. 

Australia 

Medical  inspection  of  some  kind  has  been  under- 
taken in  most  of  the  Australian  provinces.  New  South 
Wales  has  taken  up  the  work  in  a  particularly  compre- 
hensive way,  laying  stress  upon  the  cooperation  of 
teachers. 

The  results  of  medical  inspection  in  a  country  like 
Australia  have  special  interest,  for  the  reason  that  they 
may  be  expected  to  afford  an  index  of  the  influence 
upon  children's  health  of  exceptionally  favorable  eco- 
nomic and  climatic  conditions.  Thus  far  the  results 
are  no  less  disturbing  than  the  disclosures  brought 
about  by  medical  inspection  in  other  countries. 

Japan  , 

The  Japanese,  who  never  do  educational  things  by 
halves,  have  one  of  the  most  thoroughgoing  systems  to 
be  found  in  the  world.  They  rightly  regard  the  school 
child  as  the  nation's  most  valuable  asset,  and  consider 
it  a  matter  of  national  expediency  as  well  as  duty  to 
explore  the  extent  and  quality  of  this  resource.  Ac- 
cordingly most  of  the  public  schools  have  been  annu- 
ally inspected  by  salaried  school  physicians  since  1898. 
Annual  records  are  made  of  height,  weight,  chest  cir- 
cumference, nutrition,  and  all  forms  of  defectiveness. 


300        HEALTH  WORK  IN  THE  SCHOOLS 

The  resulting  statistics  are  among  the  most  complete 
and  valuable  ever  collected. 

Other  countries 

Thus  we  see  that  most  of  the  civilized  countries  of 
the  world  have  some  system  or  other  of  school  medical 
supervision.  Among  others  not  previously  mentioned 
are  Hungary,  Austria,  Belgium,  Holland,  Roumania, 
Bulgaria,  Chile,  Argentine  Republic,  South  Africa,  and 
even  individual  cities  in  such  semi-benighted  countries 
as  Russia  and  Egypt. 

The  United  States 

Medical  inspection  of  schools  in  the  United  States  is 
of  very  recent  growth.  Beginning  in  Boston  in  1894,  it 
was  taken  up  by  Chicago  in  1895,  by  New  York,  in 
1897,  and  by  Philadelphia  in  1898.  At  least  90  cities 
had  medical  inspection  in  1907,  337  in  1910,  and  prob- 
ably not  far  from  500  in  1913.  This  includes  practi- 
cally all  of  the  larger  cities  and  many  of  the  smaller. 
In  1910  the  cities  of  the  country  employed  1194  school 
doctors  and  371  nurses,  while  48  employed  school 
dentists. 

By  May,  1911,  nineteen  States  had  passed  laws  pro- 
viding for  the  medical  inspection  of  schools.  In  nine 
States  the  laws  are  mandatory.  A  few  States  have  since 
begun  the  establishment  of  State  Departments  of 
Child  Hygiene. 

Attention  may  be  called  to  the  following  salient  facts 
regarding  medical  inspection  of  schools  in  the  United 


WHAT  THE  WORLD  IS  DOING  301 

States:  (1)  The  control  is  usually  vested  in  the  board 
of  education,  instead  of  the  public  health  author- 
ities; (2)  of  the  301  cities  supporting  a  school  med- 
ical service,  nearly  half  confine  their  work  to  the 
detection  and  control  of  contagious  disease;  (3)  only 
one  State  (New  Jersey)  has  a  mandatory  provision 
requiring  treatment  for  defects  discovered;  (4)  tests  of 
vision  and  hearing  are  usually  made  by  the  teachers; 
(5)  the  movement  is  growing  with  greater  momentum 
each  year;  (6)  the  office  of  school  physician  is  still 
wretchedly  underpaid. 

Only  sporadic  attempts  have  yet  been  made  in  the 
United  States  to  introduce  school  feeding  or  school 
dentistry.  Open-air  schools  are  becoming  extremely 
popular,  the  number  increasing  enormously  each  year. 
In  the  way  of  special  schools  for  defectives  we  cannot 
yet  match  the  admirable  system  of  auxiliary  schools  in 
Germany,  but  the  movement  is  being  vigorously 
pushed. 

The  American  Association  of  School  Hygiene  was 
organized  in  1907,  and  has  published  four  volumes  of 
Proceedings.  Unfortunately  we  have  no  journal  de- 
voted to  school  hygiene.  It  is  hoped  that  the  fourth 
meeting  of  the  International  Congress  of  School 
Hygiene,  which  occurred  at  Buffalo  in  1913,  will  result 
in  increased  momentum  to  our  school  health  reform. 

Conclusion 

It  is  surely  evident,  even  from  this  brief  account, 
that  the  medical  inspection  of  schools  is  a  movement 


302        HEALTH  WORK  IN  THE  SCHOOLS 

of  great  portent.  /A  little  time  hence  we  shall  doubt- 
less look  back  upon  the  marvelous  development  of 
intellectual  education  of  the  nineteenth  century,  and 
its  simultaneous  neglect  of  the  body,  as  one  of  the 
strange  paradoxes  of  educational  history. 

Attention,  however,  should  be  called  to  the  fact  that 
in  most  countries  the  medical  service  for  secondary 
schools  has  been  made  a  matter  of  slight  consideration. 
It  is  right  that  those  schools  which  contain  the  masses 
of  the  nation's  children  should  be  provided  for  first, 
but  similar  action  should  follow  for  all  other  types  of 
schools.  The  old  assumption  that  because  children 
attending  the  higher  schools  are  usually  from  a  better 
class  of  homes,  they  must  therefore  be  practically  free 
from  defect,  has  been  entirely  disproved.  If  it  be  true, 
as  seems  probable,  that  the  secondary  schools  enroll, 
on  an  average,  pupils  of  somewhat  more  than  ordinary 
native  endowment,  then  so  much  the  more  important 
for  them  are  the  things  which  concern  health. 

REFERENCES 

*1.  Ayres,  Leonard  P.:  Medical  Inspection  Legislation.  Bulletin 
no.  99,  Russell  Sage  Foundation,  Dept.  Child  Hygiene,  1511. 

*2  Ayres,  Leonard  P.:  "What  American  Cities  are  doing  for  the 
Health  of  School  Children."  The  Public  Health  Movement, 
1911,  pp.  250-60.  Published  by  the  American  Academy  of 
Political  and  Social  Science. 

3.  Burnham,  William  H.:  "Health  Inspection  in  the  Schools." 
Ped.  Sem.,  1900. 

4.  Crowley,  Dr.  R.  H.:  The  Hygiene  of  School  Life.  1909. 

5.  Dufestel,  Dr.  L.:  Guide  Pratique  de  MSdicin  Inspecteur  des 
ftcoles.  Paris,  1910. 

6.  Franke,  Kurt:  " Schulhygiene in  Japan."  Zt.f.Schulges.,  1912, 
pp.  729-39. 

*7.  Gulick  and  Ayres:  The  Medical  Inspection  of  Schools.  1913. 


WHAT   THE   WORLD   IS   DOING  303 

*8.  Hogarth,  A.  H.:    The  Medical  Inspection  of  Schools,  1909. 

(Chapter  n,  "History  and  Legislation.") 
*9.  Kelynack,  T.   N.:    The  Medical    Inspection    of   Schools  and 

Scholars.  1910,  pp.  434.  (Best  summary  on  medical  inspection 

progress.) 
*10.  Shafer,  George  H.:  "Health  Inspection  of  Schools  in  the  United 

States."  Fed.  Sew.,  1911,  pp.  273-314. 

11.  Scot,  Vere:  "The  Blight  on  Irish  Schools."  School  Hygiene, 
1912,  pp.  230-33. 

12.  Terman,  Lewis  M.:  "Medical  Inspection  of  Schools  in  Cali- 
fornia." Psych.  Clinic,  March,  1911. 

*13.  Terman,  Lewis  M.:  The  Hygiene  of  the  School  Child.  1913. 

14.  Terman,  Lewis  M.:  The  Teachers  Health.   1913. 

15-  See  the  Proceedings  of  the  International  Congresses  of  School 
Hygiene,  1904,  1907,  1910,  and  1913;  also  the  Annual  Reports 
of  the  American  Congresses  of  School  Hygiene,  from  1907;  the 
most  important  journals  of  school  hygiene,  such  as  Zeitschrift 
fur  Schulges;  Inter.  Mag.  of  Sch.  Hyg.,  and  the  (English) 
Journal  of  School  Hygiene. 


APPENDIX 

SCHOOL  HEALTH  ORGANIZATION  IN   VARIOUS 
CITIES  OF  THE  UNITED  STATES 

Milwaukee 

The  Milwaukee  School  Health  Department  is  maintained 
by  the  Board  of  Education,  and  has  (1913)  the  following 
organization :  — - 

One  medical  director. 

Ten  assistant  medical  inspectors. 

One  specialist  on  diseases  of  the  eye,  ear,  nose,  and  throat. 

One  full-time  dental  inspector. 

One  special  assistant  for  psychological  and  anthropologi- 
cal tests. 

Five  school  nurses. 

The  medical  director,  dental  inspector,  and  nurses,  devote 
their  entire  time  to  their  work;  the  remainder  of  the  staff 
give  one  half  of  each  day.  A  central  office  is  maintained 
where  the  medical  director  meets  parents,  conducts  special 
examinations,  and  carries  on  the  general  office  work  of  the 
department.  A  dental  clinic  for  indigent  children,  an  out- 
door school,  and  a  school  for  crippled  children,  have  re- 
cently been  added.  There  are  four  classes  for  blind  children, 
and  four  centers  for  the  treatment  of  speech  defects. 

The  city  has  been  divided  into  ten  geographical  districts, 
nine  of  which  are  approximately  equal  in  size  and  contain 
about  the  same  number  of  schools;  the  tenth,  located  in  the 
central,  or  slum,  portion  of  the  city,  covers  less  area  because 
the  schools  are  closer  together  and  the  conditions  met 
among  the  pupils  worse  than  in  the  outlying  sections  of  the 
city.  Each  district  is  under  the  care  of  one  assistant  medical 
inspector.  For  the  work  of  the  nurses,  the  city  has  been 
divided  into  five  districts,  the  four  outlying  territories  being 
about  equal,  and  the  fifth  in  the  center  of  the  city,  being 
considerably  smaller. 


306  APPENDIX 

Each  school  has  been  supplied  with  the  following  mate- 
rials:— 

1.  A  case  for  the  filing  of  the  doctor's  and  nurse's  rec- 
ords. 

2.  A  circular  for  the  principal,  explaining  in  brief  the 
purposes  of  medical  inspection,  his  duties  in  its  accomplish- 
ment, and  information  as  to  causes  and  time  of  exclusions. 

3.  A  circular  for  each  teacher,  detailing  her  duties,  and 
giving  information  as  to  the  early  symptoms  of  contagious 
diseases. 

4.  Code  cards  for  all  teachers  on  which  all  diseases  of 
importance  are  indicated,  by  numbers. 

5.  Blue  cards,  for  requests  from  teachers  for  an  immediate 
examination. 

6.  Psychological  examination  blanks,  with  circular  of 
explanation. 

7.  Physical  examination  blanks. 

8.  An  emergency  case,  containing  a  stretcher,  drugs,  and 
dressings. 

Complete  directions  are  given  to  the  medical  inspectors 
and  nurses  in  respect  to  their  routine  work  in  the  schools. 
Principals  of  schools  are  also  instructed  in  respect  to  the 
general  plan  of  health  supervision.  Indigent  children,  suf- 
fering from  physical  defects,  are  referred  to  the  various 
city  dispensaries. 

The  general  plan  of  examination  is  as  follows:  — 
A  blue  card  constitutes  the  request  of  the  teacher  for  an 
examination  for  one  of  her  pupils,  whom  she  suspects  of  be- 
ing afflicted  with  some  acute  condition  requiring  immediate 
care.  When  the  class  assembles  in  the  morning,  the  teacher 
rapidly  inspects  her  pupils,  and  if  she  finds  anything  abnor- 
mal in  the  appearance  of  a  child  she  makes  out  this  card. 
On  this  card  she  gives  the  name,  address,  school,  grade, 
teacher,  date,  and  reason  for  sending  the  child.  When  the 
doctor's  signal  is  given,  or  a  monitor  informs  her  of  the 
doctor's  presence  in  the  school,  she  gives  the  child  selected 
for  examination  its  blue  card,  and  sends  it  to  the  room  in 
which  the  doctor  makes  his  examinations.  The  doctor  ex- 
amines each  child  presented,  makes  his  diagnosis,  and  on 
the  stub  attached  informs  the  teacher  of  his  findings,  whether 
the  child  is  to  be  excluded  or  not,  and,  if  excluded,  for  how 


APPENDIX  307 

long.  The  card  itself  is  placed  on  file,  and  the  case  followed 
up  by  nurse  and  doctor  until  cured,  when  the  card  is  sent 
to  the  central  office  for  tabulation.  If  the  case  is  such  that 
the  doctor  considers  exclusion  desirable,  a  yellow  card  is 
made  out,  giving  the  cause  for  exclusion,  the  date  on  which 
the  child  is  to  report  for  reexamination,  and  the  date  of  re- 
examination and  readmission.  Attached  to  this  card  is  a 
letter  form  which  is  sent  home  in  a  sealed  envelope  with 
the  child,  informing  the  parents  of  the  exclusion  and  the 
cause. 

Each  child  in  the  schools  receives  also  a  physical  examina- 
tion. The  result  of  this  examination  is  kept  on  a  blank  made 
out  in  duplicate,  and  so  arranged  as  to  provide  for  annual 
records  for  a  period  of  nine  school  years.  The  information 
recorded  on  the  blank  comprises  the  name,  birthplace,  sex, 
age,  school,  grade,  nationality  of  father  and  mother,  history 
of  measles,  scarlet  fever,  diphtheria,  pertussis,  date  of  phy- 
sical examination,  vaccinations,  height,  weight,  nutrition, 
presence  or  absence  of  hypertrophied  tonsils,  adenoids,  de- 
fective nasal  breathing,  defective  palate,  defective  teeth, 
myopia,  hypermetropia,  other  eye  defect,  defective  hearing, 
deformities  of  the  spine,  trunk  or  extremities,  tubercular 
lymph  nodes,  pulmonary,  cardiac  or  nervous  disease,  chorea, 
epilepsy  or  stammering.  One  copy  is  sent  to  the  central 
office  and  one  copy  is  placed  on  file  at  the  school,  so  that  the 
principal  and  teacher  may  know  the  physical  condition  of 
each  child  in  the  school.  When  the  child  is  placed  under 
another  teacher,  either  by  promotion,  demotion,  or  transfer 
to  another  school,  the  card  is  presented  to  this  teacher,  who 
is  thereby  informed  concerning  any  defects  which  the  new 
pupil  may  have. 

The  Milwaukee  system  is  as  near  ideal  as  any  in  the  coun- 
try, and  is  thoroughly  practical  and  efficient  in  organiza- 
tion and  results  obtained.  Schools  expecting  to  undertake 
complete  health  supervision  of  their  pupils  cannot  do  better 
than  to  study  the  Milwaukee  system. 

Health   Organization   in   the   Minneapolis   Schools 

This  department  is  organized  to  include,  so  far  as  possi- 
ble, all  matters  pertaining  directly  to  the  health  of  the  child. 


308  APPENDIX 

It  therefore  includes  all  the  physical  training  activities, 
gymnastics,  folk-dancing,  athletics,  both  high  and  grade 
school,  those  playgrounds  that  are  conducted  by  the  board 
of  education,  whatever  physical  training  work  is  done  in 
the  night  schools,  etc. 

The  school  for  stammerers,  special  classes  for  children  who 
are  mentally  retarded  and  deficient,  open-air  schools,  the 
school  gardens,  and  the  truant  schools  are  also  all  under  the 
general  supervision  of  the  school  health  department. 

The  official  organization  is  as  follows :  — 

One  medical  director  (on  full  time). 

Eight  assistant  medical  officers  (on  half  time). 

Eighteen  school  nurses  (on  full  time), 
r Twelve  instructors  in  physical  training  (on  full  time). 

Eighteen  playground  instructors  during  the  summer 
months. 

One  supervising  school  nurse. 

The  work  of  the  Minneapolis  School  Health  Department 
is  maintained  by  the  board  of  education,  and  is  one  of  the 
most  efficient  departments  now  organized.  It  is  interesting 
to  note  with  what  completeness  the  divisions  of  medical 
supervision  and  physical  education  are  organized  and  re- 
lated in  this  city. 

Philadelphia 

Philadelphia,  under  the  management  of  Dr.  Walter 
Cornell,  has  recently  reorganized  its  school  health  work  as 
follows:  — 

The  examination  of  school  children  is  conducted  by  the 
city  health  department,  but  the  expense  is  borne  by  the 
board  of  education.  Under  ordinary  conditions  this  plan 
could  not  be  recommended,  but  at  present  it  appears  to 
work  satisfactorily  in  Philadelphia.  The  school  nurses  are 
employed  and  paid  by  the  board  of  education. 

The  scope  of  the  work  at  present  includes :  — 

1.  Routine  examination  of  every  child  once  each  year,  as 
required  by  the  state  law. 

2.  Sanitary  inspection  of  school  buildings. 

3.  The  detection  and  exclusion  of  children  suffering  from 
contagious  diseases. 


APPENDIX  309 

4.  The  examination  of  absentee  children,  for  the  Bureau 
of  Compulsory  Education. 

5.  Special  examination  of  mentally  deficient  children. 

6.  Medical  supervision  of  open-air  classes  for  anaemic  and 
tubercular  children. 

7.  Examination  of  applicants  for  position  of  school  janitor, 
and  other  positions  in  the  department  of  buildings. 

8.  Medical  supervision  of  special  classes  for  blind  or 
crippled. 

9.  The  supervision  of  candies  and  other  foodstuffs  sold 
by  vendors  around  the  school  premises  is  being  projected, 
and  will  soon  be  put  into  effect. 

Oakland 

Oakland,  California,  has  had  since  1909  an  excellent  or- 
ganization under  the  direction  of  Dr.  N.  K.  Foster.  The 
plan  is  in  some  respects  unique,  and  has  given  splendid  results. 
It  consists  of  the  following :  — 

One  medical  director. 

One  assistant  medical  officer. 

Seven  school  nurses. 

Each  nurse  has  her  own  particular  schools  in  which  to 
work.  At  the  beginning  of  the  year  a  special  attempt  is 
made  to  give  attention  first  to  those  pupils  who  are  urgently 
in  need  of  it.  This  is  accomplished  through  the  efforts  of 
the  teachers  and  nurses.  In  this  way  the  worst  cases  are 
detected  and  followed  up  early  in  the  year,  a  point  of  much 
importance.  After  this  preliminary  work  is  finished,  the 
nurse  examines  all  of  the  pupils  in  her  district,  and  sends 
notices  of  defects  discovered  to  parents.  Follow-up  work 
is  done  in  the  case  of  each  child  whose  parents  receive  a 
notice. 

An  interesting  and  valuable  part  of  the  nurse's  work  con- 
sists in  simple  "health  talks"  to  the  individual  pupils,  at 
the  time  of  the  physical  examination,  particularly  in  rela- 
tion to  the  defects  or  disorders  from  which  they  suffer. 
Health  talks  are  also  given  the  entire  classes  both  by  the1 
school  nurses  and  school  doctors,  and  special  attention  is 
given  to  instruction  in  matters  pertaining  to  sex-hygiene. 

A  central  office  is  maintained  by  the  board  of  education 


310 


APPENDIX 


at  which  the  school  physicians  keep  office  hours,  so  that 
parents  may  come  with  their  children  for  special  examina- 
tions and  consultations  in  respect  to  further  action. 

The  entire  department  is  maintained   by  the  board  of 
education,  and  the  plan  works  admirably  in  every  respect. 


Health  Organization  in  New  York  City  Schools 

The  medical  supervision  of  school  children  in  New  York 
City  is  maintained  under  the  division  of  child  hygiene  of 
the  city  board  of  health.  The  division  of  child  hygiene  was 
reorganized  in  1912,  and  at  present  consists  of  the  following 
plan :  — 


Organizai 

ion  c 

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DIRECTOR. 

Assistant  Director. 
Supervising  Inspector 
Superintendent  of  Nui 

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attan 

Borou 
Broo 

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Bore 
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Super 
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:tors 

Super 
Inspe 

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Super 
Inspe 

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Super. 
Inspec 

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Supei 
Inspe 

vising 
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Super 

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Super 
Nui 

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■ses 

Super 
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Super 
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Supei 

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Medi 
Inspe 

al 

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Medic 
Inspe 

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Medic 
Inspe 

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Medic 
Inspe 

al 
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Medic 
Inspe 

al 

ctors 

Nurses 

Nurses 

Nurses 

Nurses 

Nurses 

Nurses' 
Assistants 

Nurses' 
Assistants 

Nurses 
Assistants 

Nurses' 
Assistants 

Nurses' 
Assistants 

APPENDIX  311 

Borough  Organization 

Borough  chief,  in  each  borough.  (Directly  responsible  to  the 
director,  and  in  charge  of  the  indicated  borough.) 

Supervising  inspectors.  (Each  in  charge  of  a  squad  of 
from  ten  to  fifteen  inspectors  and  under  the  direct  super- 
vision of  the  borough  chief.) 

Supervising  nurses.  (Each  in  charge  of  a  squad  of  from 
fifteen  to  twenty  nurses,  and  directly  responsible  to  the 
supervising  inspectors.) 

Medical  inspectors. 

Nurses. 

Nurses'  assistants. 

Under  the  subdivision  of  school  hygiene  there  are  em- 
ployed, in  addition  to  the  supervising  school  medical  officers 
and  supervising  school  nurses,  74  medical  inspectors  and 
179  school  nurses.  The  control  of  contagious  diseases  has 
been  placed  in  the  hands  of  the  school  nurses,  while  the 
medical  officers  in  the  schools  devote  their  time  to  the  work 
of  making  physical  examinations.  School  nurses  treat  many 
of  the  eye  and  skin  diseases  discovered  in  the  schools,  while 
free  dispensary  treatment  is  provided  for  all  other  cases 
which  cannot  receive  attention  from  family  physicians  and 
specialists. 

Present  Procedure 
Objects:  — 

1.  The  repeated  and  systematic  inspection  of  all  school 
children  for  the  purpose  of  early  recognition  of  conta- 
gious disease. 

2.  Exclusion  from  school  attendance  of  all  children  af- 
fected with  an  acute  contagious  disease. 

3.  Subsequent  control  of  the  case  with  isolation  of  the 
patient,  and  disinfection  of  the  living  apartment  after 
termination  of  the  illness. 

4.  Control  and  enforced  treatment  of  contagious  eye  and 
skin  diseases  with  the  purpose  of  diminishing  the  num- 
ber of  children  excluded  from  school  attendance. 

5.  Knowledge  of  unreported  cases  of  contagious  disease 
among  school  children  at  home. 


312  APPENDIX 

6.  Complete  physical  examination  of  each  school  child 
with  reference  to  the  existence  of  any  untreated  phys- 
ical abnormality. 

7.  Education  of  the  parents  as  to  the  necessity  of  ob- 
taining proper  medical  care  for  untreated  physical 
defects. 

8.  Provision  for  facilities  for  the  treatment  of  contagious 
eye  and  skin  diseases  and  non-contagious  physical 
defects  occurring  in  school  children. 

The  complete  system  of  school  medical  inspection  is 
carried  on  in  517  public  schools  with  a  registered  attendance 
of  684,207  pupils.  In  addition,  151  other  free  schools  of  the 
city  receive  a  more  or  less  complete  series  of  inspections  for 
the  purpose  of  detecting  contagious  diseases.  Seventy-four 
medical  inspectors  and  179  nurses  are  detailed  to  the  work 
of  school  medical  inspection  under  the  immediate  super- 
vision of  the  staff  of  supervising  inspectors  and  supervising 
nurses  in  each  borough.  Each  inspector  is  assigned  to  duty 
in  a  group  of  schools  with  an  average  registration  of  nine 
thousand  pupils.  Each  nurse  is  assigned  to  duty  in  a  group 
of  schools  with  an  average  registration  of  four  thousand 
pupils. 

Each  public  school  in  the  city  is  visited  each  day  by  a 
nurse,  except  in  certain  outlying  and  sparsely  populated 
districts  where  visits  are  made  at  less  frequent  intervals. 
Other  free  schools  are  visited  upon  request,  or  regularly 
once  or  twice  weekly. 

The  school  medical  officers  follow  the  routine  indicated 
in  the  outline  which  is  given  below :  — 

The  diagnosis  and  correction  of  non-contagious  untreated  'phys- 
ical defects:  — 

1.  The  medical  inspector  visits  each  school  under  his 
jurisdiction  for  two  successive  days.  A  regular  schedule 
is  maintained,  and  the  principals  of  the  schools  are 
thus  informed  of  the  dates  of  the  inspector's  visits. 
The  principals  are  requested  to  instruct  the  children 
to  report,  in  small  squads,  to  the  inspector  for  physical 
examination. 

2.  Examinations  are  made  in  the  following  order:  — 
(a)  Children  entering  school  for  the  first  time. 


APPENDIX  313 

(b)  Children  especially  referred  by  the  principals  or 
teachers. 

(c)  Children  belonging  to  the  class  to  be  graduated. 

(d)  In  the  regular  course,  beginning  with  children  of 
the  lowest  grades,  and  proceeding  to  the  higher 
grades  in  regular  order. 

(e)  Classes  of  the  same  grade  are  examined  in  regular 
order  in  each  school  of  the  group. 

3.  Each  child  is  thoroughly  examined  for  the  following 
conditions :  — 

Defective  vision. 
Defective  hearing. 
Defective  nasal  breathing. 
Hypertrophied  tonsils. 
Tuberculous  lymph  nodes. 
Defective  teeth. 
Malnutrition. 
Pulmonary  disease. 
Cardiac  disease. 
Chorea. 
Orthopaedic  defects. 

4.  A  complete  record  of  each  physical  examination  is  made 
on  a  special  form.  If  a  child  is  normal,  the  inspector 
sends  such  a  report  to  the  borough  office  of  the  divi- 
sion. If  abnormalities  are  found,  the  record  form  is 
given  to  the  school  nurse. 

A  duplicate  record  of  each  child's  condition  is  also  placed 
on  file  with  the  child's  school  record,  thus  affording  to  the 
educational  authorities  the  fullest  information  in  regard  to 
the  child's  physical  condition,  and  enabling  them  to  take 
advantage  of  this  information  in  adjusting  the  individual 
curriculum. 

The  nature  and  results  of  the  treatment  obtained  for  each 
defect  are  thereafter  noted  upon  this  school  record  form  by 
the  nurse. 

The  inspectors  and  nurses  are  required  to  cooperate  to  the 
fullest  extent  with  the  principals  and  teachers,  giving  to 
them  all  possible  data  in  relation  to  the  children  found  to  be 
physically  defective,  and  to  offer  suggestions  in  the  way  of 
school  adjustments  which  may  tend  to  correct  the  existing 
defects. 


314  APPENDIX 

The  cities  cited  furnish  practical  information  of  what  is 
actually  being  accomplished  in  some  of  the  representative 
places  of  the  United  States,  and  will  thus  indicate  to  other 
cities  of  a  similar  size  how  organization  may  be  successfully 
begun.1 

1  For  an  intensive  study  of  the  methods  and  results  of  medical 
inspection  in  twenty-five  representative  cities  of  the  United  States, 
see  Louis  W.  Rapeer:  School  Health  Administration.   1913,  pp.  360. 


SUGGESTIONS 

FOR  A  TEACHER'S    PRIVATE  LIBRARY  IN 
SCHOOL  HYGIENE 

A.  General 

(A  selected  list  of  sixteen  of  the  best  books,  which  retail  for  a  total 
of  $30.25.) 

1.  Allen,  W.  H.:  Civics  and  Health.  Ginn  &  Co.,  Boston, 

1909,  pp.  411;  price  $1.50. 

2.  Ayres,  Leonard  P.:  Open-Air  Schools.  Doubleday, 
Page  &  Co.,  New  York,  1910,  pp.  165;  price  $1.00. 

3.  Bryant,  Louise  Stevens:  School  Feeding.  Lippincott 
Co.,  Philadelphia,  1913,  pp.  345;  price  $1.50. 

4.  Cornell,  Walter  S.:  The  Health  and  Medical  In- 
spection of  School  Children.    Davis  Co.,  Philadelphia, 

1912,  pp.  614;  price  $3.00. 

5.  Crowley,  Ralph  H.:  The  Hygiene  of  School  Life. 
Methuen  &  Co.,  London,  Eng.,  1910,  pp.  393;  price 
$1.50. 

6.  Denison,  Elsa:  Helping  School  Children.  Harper  & 
Bros.,  New  York,  1913,  pp.  352;  price  $1.50. 

7.  Dresslar,  F.  B.:  School  Hygiene.  The  Macmillan  Co., 
New  York,  1913,  pp.  369;  price  $1.25. 

8.  Gulick,  Luther,  and  Ayres,  L.  P. :  The  Medical  In- 
spection of  Schools.  Russell  Sage  Foundation,  New  York, 

1913,  pp.  224;  price  $1.50. 

9.  Hoag,  E.  B.:  The  Health  Index  of  Children.  Whitaker 
and  Ray-Wiggin  Co.,  San  Francisco,  1910,  pp.  188; 
price  $.80. 

10.  Hogarth,  A.  H.:  The  Medical  Inspection  of  Schools. 
Oxford  University  Press,  London,  Eng.,  1909,  pp.  360; 
price  $1.50. 

11.  Kelynack,  T.  N.:  (editor)  The  Medical  Examination 
of  Schools  and  Scholars.  P.  S.  King  &  Son,  London,  Eng., 

1910,  pp.  434;  price  $3.00. 


316         A  TEACHER'S  PRIVATE  LIBRARY 

12.  Leland,  Arthur:  Playground  Teaching  and  Playcraft; 
price  $2.70. 

13.  Rapeer,  Louis  W.:  School  Health  Administration. 
Teachers  College,  1913,  pp.  360;  price  $2.25. 

14.  Terman,  Lewis  M.:  The  Hygiene  of  the  School  Child. 
Houghton  Mifflin  Co.,  Boston,  1913,  pp.  450;  price  $1.65. 

15.  Terman,  Lewis  M.:  The  Teacher's  Health.  Houghton 
Mifflin  Co.,  Boston,  1913,  pp.  138;  price  $.60. 

16.  Proceedings  of  the  Fourth  International  Congress  of 
School  Hygiene,  held  at  Buffalo,  1913,  three  volumes; 
price  $5.00.  Address  Thomas  A.  Storey,  College  of  the 
City  of  New  York. 

B.  The  Teaching  of  Hygiene 

(A  selected  list  of  the  best  books,  which  retail  for  a  total  of 
$6.83). 

1.  Gulick,  Luther  H.:  The  Gulick  Hygiene  Series.  Ginn 
&Co.,  Boston.  " Two-Book  Course,"  $1.05;  "Five- 
Book  Course,"  $2.30. 

2.  Hoag,  E.  B.:  Health  Studies.  D.  C.  Heath  and  Co., 
Boston,  1909,  pp.  223;  price  $.60. 

3.  Hutchinson,  Woods:  The  Woods-Hutchinson  Health 
Series,  two  volumes,  Houghton  Mifflin  Co.,  Boston; 
"Book  One:  The  Child's  Day,"  $.40:  "Book  Two: 
Handbook  of  Health,"  $.65. 

.  -  4.  Ritchie  and  Caldwell:  Primer  of  Hygiene,  and  Primer 
of  Sanitation.  World  Book  Company,  Yonkers-on-Hud- 
son,  New  York.  The  two  for  $1.08. 

5.  Wood  and  Reesor:  Health  Instruction  in  the  Elementary 
Schools.  Teachers  College,  New  York,  1912,  pp.  140; 
price  $.25. 

6.  Tolman  and  Guthrie :  Hygiene  for  the  Worker.  American 
Book  Co.,  1912,  pp.  231;  price  $.50. 


GLOSSARY 


anaemia,  deficiency  of  blood, 
or  of  red  corpuscles. 

arthritis,  inflammation  of  a 
joint. 

astigmatism,  a  refractive  error 
of  vision  due  to  unequal  cur- 
vature of  the  parts  of  the  eye. 

atypical,  not  typical,  excep- 
tional. 

aurist,  a  specialist  in  diseases 
of  the  ear. 

bacteriology,  the  department 
of  zoology  which  deals  with 
bacteria. 

blood-count,  referring  to  the 
number  of  corpuscles  per 
unit  measure  of  blood. 

Blight's  disease,  a  disease  of 
the  kidneys. 

carious,  decayed. 

cervical  glands,  the  lymph 
glands  of  the  neck. 

chorea,  "St.  Vitus's  Dance." 

conjunctivitis,  an  inflamma- 
tory disease  of  the  mucous 
membrane  lining  the  eyelids. 

dentine,  the  calcified  sub- 
stance which  composes  the 
main  part  of  a  tooth. 

desquamation,  peeling-off  of 
the  skin. 

eugenics,  the  science  of  im- 
proving    the     human     race 


through   the   application   of 
the  laws  of  heredity, 
exhalation,  the  expulsion  of  air 
from  the  lungs. 

fomite  infection,  the  spread  of 
contagious  diseases  through 
the  medium  of  articles  or 
things. 

haemoglobin,  that  part  of  the 
red  corpuscles  whose  func- 
tion is  to  carry  oxygen. 

hydrocephaly,  a  disease  char- 
acterized by  the  accumula- 
tion of  a  watery  fluid  on  the 
brain. 

hyperopia,  "far  sight." 

hypertrophied,  abnormally  en- 
larged, overgrown. 

hyphosis,  backward  curvature 
of  the  spine. 

impetigo,  a  contagious  skin  dis- 
ease due  to  a  fungus. 

lassitude,  weakness  or  languor, 
lymphatic,    pertaining    to    the 
lymph. 

mastoid,  that  part  of  the  tem- 
poral bone  situated  directly 
behind  the  ear. 

moron,  that  grade  of  feeble- 
mindedness just  below  the 
normal. 

myopia,  "near  sight." 


318 


GLOSSARY 


neurosis,  any  nervous  disor- 
der. 

oculist,  a  physician  skilled  in 
treating  diseases  of  the  eye. 

Optician,  one  who  makes  or 
deals  in  optical  instruments 
or  glasses. 

oral  hygiene,  the  hygiene  of  the 
mouth. 

orthodontia,  mechanical  treat- 
ment for  correcting  irregu- 
larity of  the  teeth. 

otitis  media,  acute  infection  of 
the  middle  ear. 

passee,  faded,  worn  out. 
pediculi  capitis,  head  lice, 
poliomyelitis,  a  disease  of  the 

gray    matter    of    the    spinal 

cord, 
polypus,  a  tumorous  growth  on 

the  mucous  membrane,  as  of 

the  nose. 


radiograph,  an  X-ray  picture, 
rickets,  a  nutritional  disease  of 

childhood    affecting     chiefly 

the  bones. 

scabies,  itch. 

scoliosis,  lateral  curvature  of 

the  spine, 
squint,  cross-eye,  or  strabismus, 
strabismus,  cross-eye. 
suppuration,  producing  pus. 

tie,  a  spasmodic  twitching  of 
the  muscles. 

toxaemia,  a  poisoned  condition 
of  the  blood. 

trachoma,  a  contagious  disease 
of  the  eye  involving  granula- 
tion of  the  inner  surface  of 
the  eyelids. 

varicella,  chickenpox. 
Von  Pirquet  test,  a  test  for  the 
presence  of  tuberculosis. 


INDEX 


Addams,  Jane,  52. 

Adenoids,  97  ff. 

Air,  as  a  source  infection,  141  ff. 

Australia,  school  health  work  in, 

299. 
Ayres,  Leonard  P.,  7,  198. 

Binet  tests,  105  ff. 

Blood  tests,  at  open-air  schools, 

203/. 
Board  of  health,  25  ff. 
Bradford,  school  medical  clinic, 

112;  open-air  school,  200. 
Burnham,  Dr.  W.  H.,  271. 

Cabot,  Dr.  R.  C,  59 

Canada,  school  health  work  in, 
298. 

"Carriers,"  142  ff.,  160/. 

Chapin,  Dr.,  141,  143,  154,  160. 

Chickenpox,  171,  192. 

Christian  Science,  11/. 

Cleaning,  method  of,  214  / 

Clinics.     See  School  clinics. 

Closure  of  schools,  142  /. 

Contagious  diseases,  133  ff.; 
modes  of  infection,  137/.;  an- 
nual curve,  145. 

Cornell,  Dr.  W.,  308. 

Cups,  drinking-cups,  139/ 

Defectiveness,  91/,  253;  amount 
of,  2,  87  /.;  discovery  by 
teachers,  68  /.;  treated  by 
school  clinics,  111  /  See  also 
Eyes,  Ears,  Teeth,  Nutrition, 
Nose,  Throat,  etc. 

Denmark,  school  health  work  in, 
295. 

Dental  caries,  130/ 

Departments  of  health  in  the 
school,  7/,  305/ 

Diphtheria,  135,  143, 159/,  184, 
194. 


Disinfection,  152. 
Dock,  Dr.,  178-79. 
Dust,  209  / 
Dustless  crayon,  216. 

Earache,  80. 

Ears,  71,  115. 

England,  school  health  work  in, 

285/. 
Epidemic  meningitis,  181  / 
Eyes,  72,  80,  84  /,  92  /.,  116, 

182/. 

Favus,  189. 

Feeble-mindedness,  105/ 

Feeding,  in  open-air  schools,  199. 

Flexner,  182. 

Fomite  infection,  137/. 

Food,  88. 

Food  habits,  228. 

Forsyth  Dental  Infirmary,  128. 

Foster,  Dr.  N.  K.,  309. 

France,  school  health  work  in, 

290/ 
Fiirst,  Dr.  Clyde,  286. 

Germany,  school  health  work  in, 

287/. 
Gonorrhoea,  252-53. 

Haberlin,  Dr.,  204. 

Hall,  Stanley,  254. 

Hall,  W.  S.,  228. 

Hay  ward,  Dr.,  49. 

Headache,  80. 

Health  supervision,  relation  of, 
to  private  medical  practice, 
6/;  opposition  to,  11  /.;  de- 
velopment of,  15  /,  285  /.; 
scope  of,  17  / ;  cost  of,  23,  45 
/.;  method  of  control,  25  /.; 
state  departments,  37  /.;  or- 
ganization of  city  departments, 
41/,  305/.;  by  nurses,  48/; 


320 


INDEX 


influence  on  home,  54  /.;  by 
teachers,  62  /.;  in  foreign 
countries,  285  ff. 

Hearing,  test  of,  99  ff.  See  also 
Ears. 

Hoag,  Dr.  E.  B.,  90,  145,  315. 

Hogarth,  Dr.  A.  H.,  109,  121. 

Hookworm  disease,  178  ff. 

Home,  influence  of  health  super- 
vision on,  10  ff.;  sanitation  of, 
241  ff.;  responsibility  for  sex 
enlightenment,  267. 

Hygiene  departments,  of  city 
schools,  305  /. 

Hygiene  teaching,  9,  103,  231/.; 
in  the  first  six  grades,  221  ff. ; 
in  the  seventh  and  eighth 
grades,  236  ff.;  by  means  of 
sanitary  surveys,  240  ff.;  sex 
education,  252  ff.;  teacher's 
hygiene  library,  315-16. 

Impetigo,  190. 
Infantile  paralysis,  180  ff. 
Influenza,  194-95. 
Intelligence  tests,  105  ff. 
Ireland,  school  health  work  in, 

297. 
Itch.  See  "Scabies." 

Janitors,  219. 

Japan,   school   health  work  in, 

299. 
Jessen,  Dr.  E.,  125. 

Kerr,  Dr.  James,  148,  154. 
Korosi,  Dr.,  133. 

Lambert,  Dr.,  213. 

"League  for  Medical  Freedom," 

11  & 
London,  school  clinics  in,  112. 

McCallie  test,  96. 
Mackenzie,  Dr.  W.  Leslie,  297. 
MacMillan,  Margaret,  112. 
Malnutrition,  176. 
Measles,  134,  149  ff.,  192. 
Medical  inspection.  See  "Health 

supervision." 
Mental  conditions,  83,  105  ff. 


Milwaukee,  school  health  work 
in,  305  /. 

Minneapolis,  health  organiza- 
tion in,  307. 

Minnesota,  state  division  of  child 
hygiene,  38/. 

Moll,  Dr.  Albert,  254. 

Moral  Education,  260. 

Mumps,  169  ff.,  194. 

Muroscroll,  216. 

Nervous  conditions,  70,  83. 

New  York  City,  school  health 
department,  310/. 

Normal  schools,  and  the  teach- 
er's health,  281. 

Norway,  school  health  work  in, 
295. 

Nose  and  throat,  71,  81,  97/. 

Nurses,  42  /. ;  48  /. ;  home  visi- 
tation, 49/.;  and  absence,  51 
/.;  number,  5Q  ff.;  training, 
57/.;  efficiency,  59/.;  health 
surveys,  66/ 

Oakland,   school  health  depart- 
ment, 309  / 
Open-air  schools,  198/ 
Orthodontia,  130. 
Osier,  Dr.,  54,  181. 

Parental  responsibility,  3  /. 
Parents,  notification  of,  104  /. 
Pediculosis  capitis,  188/ 
Philadelphia,   school  health  de- 
partment, 308  / 
Physiological  age  differences,  102 

/ 
Porter,  Dr.  Langley,  177. 
Posture,  82. 
Publicity,  33/ 

Rapeer,  Dr.  Louis,  17,  59. 
Records,  29/,  74/ 
Reinhart,  Dr.  George,  143. 
Ringworm,  189. 

Sanitary  surveys,  238. 
Sanitation,  209/ 
Scabies,  187. 
Scarlet  fever,  153/,  192. 


INDEX 


321 


School  buildings,  8. 

School  clinics,  demonstration 
clinics,  90  ff. ;  medical  clinics, 
109  /.;  cost  of,  113;  why  neces- 
sary, 114;  dental  clinics,  125 

/. 

School  nurse.   See  Nurse. 

Scotland,  school  health  work  in, 
296. 

Skin  diseases,  72,  85. 

Sleep,  at  open-air  schools,  199, 
205. 

Smallpox,  173  ff.,  194. 

Snellen  test,  84,  95. 

Social  responsibility  for  health, 
1/.,  119/. 

State  departments  of  school  hy- 
giene, 38/. 

Superannuation  of  teachers,  272. 

Sweden,  school  health  work  in, 
293/. 

Switzerland,  school  health  work 
in,  292. 

Syphilis,  253. 

Teacher,  part  in  health  super- 
vision, 62  ff.',  private  library 
in  school  hygiene,  315. 

Teacher's  health,  270/. 


Teeth,  71,  78,  85;  dental  clinics, 
125/. 

Terman,  Lewis  M.,  108,  270,  303, 
316. 

Towels,  138. 

Trachoma,  97,  185/. 

Tuberculosis,  175;  among  teach- 
ers, 273.  See  also  Open-air 
schools. 

Vaccination,  174. 

Vacuum  cleaners,  215. 

Varicella,  171. 

Virginia,  school  health  work  in, 
40/ 

Vision,  testing,  95  /.  See  also 
Eyes. 

Vocational  guidance  for  teach- 
ers, 283. 

Von  Pirquet  test,  175. 

Weight,     increase    in    open-air 

schools,  200. 
Whooping-cough,  164,  166/. 
Wichmann,  Dr.,  276. 
Wiesbaden,    examination    plan, 

288. 
Williams,  Dr.  Lewis,  111,  114, 

119,  120. 


,^wli.LMNCREASETOSOCENTHE    ^^     QAY 

DAY    AND    1 
OVERDUE. 


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JAN   26  W4* 


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YB  44635 


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UNIVERSITY  OF  CALIFORNIA  LIBRARY 


